Care Transitions & Coordination Specialist

MetroPlusHealth; New York (NY); On-site; USD 70,000 - 105,000; Full time

Job summary

MetroPlusHealth is seeking a Care Coordination Liaison to strengthen the link between MetroPlusHealth and NYC Health + Hospitals, focusing on inpatient and post-acute transitions of care. You will coordinate information exchange, perform proactive member outreach, and support care teams to improve outcomes and reduce readmissions.

The role requires a Master’s degree and at least two years in care coordination or related fields, with LMSW/LCSW licensure preferred.

Qualifications

• Master’s Degree required.
• A minimum of two years of care management/coordination, health education, health home or community-based experience required.
• Proficiency with computers, including navigation across multiple systems and web-based applications, is required.
• Must know how to use Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
• Ability to proficiently read and interpret medical records, claims data, pharmacy information, lab reports, and prescriptions is required.

Responsibilities

• Facilitates bidirectional communication between H+H providers and MetroPlusHealth Care Management teams primarily by email and Epic in-basket, triaging issues and inquiries and providing timely responses to messages to rapidly resolve challenging care management issues.
• Supports care transitions across settings, including emergency department, inpatient, skilled nursing/rehab, home health, and extramural facilities by serving as a designated point of contact to ensure communication is focused and appropriately directed.
• Ensures continuity of care through timely appointment scheduling; integration of discharge summaries into EPIC; provider and/or member/caregiver notifications, outreaches and follow ups, primarily using Epic messaging; and escalates untimely appointment access as needed.
• Conducts targeted outreach to select members at risk of readmission and those requiring assistance with appointments, transportation, Durable Medical Equipment (DME), medication, social drivers of health, and related care coordination needs.
• Collaborates with care management leadership and multidisciplinary teams to identify and track recurring complex care management challenges and systemic barriers, especially those that require coordination across teams; support cross-organizational solutions that can improve patient/ member outcomes.

Skills

Communication skills

MS Office

Medical records interpretation

Care coordination

Education

Master’s Degree

LMSW or LCSW license

Tools

Epic

Job description

MetroPlusHealth is seeking a Care Coordination Liaison to strengthen the link between MetroPlusHealth and NYC Health + Hospitals, focusing on inpatient and post-acute transitions of care. You will coordinate information exchange, perform proactive member outreach, and support care teams to improve outcomes and reduce readmissions.

The role requires a Master’s degree and at least two years in care coordination or related fields, with LMSW/LCSW licensure preferred.