Health Home Care Coordinator & Liaison

Northwell Health; Manhasset (NY); On-site; USD 52,000 - 70,000; Full time

Job summary

Northwell Health is seeking a Care Management Coordinator to coordinate and participate in Care Management services for families and caregivers. Health Home Plus serves defined populations with SMI enrolled in HHSA, using patient-centered motivational interviewing to build rapport and improve health.

You will support the primary care team by panel management to reduce patients lost to care, and help develop and adjust individualized care plans for high-risk patients addressing medical and social

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience, required.
• Bachelor's or Master's degree in relevant field strongly preferred.
• A CASAC and two years of experience; OR a Bachelor’s degree or higher with relevant experience in SMI/SED population strongly preferred.
• NYS Driver's License strongly preferred.

Responsibilities

• Utilizes patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
• Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care or disconnected from primary care.
• Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients addressing medical and social barriers.
• Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources to ensure patient-centered care coordination.
• Identifies and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services.
• Identifies and tracks patients discharged from the inpatient service or the emergency department.
• Uses team-based communication strategies to close the loop on referrals, hospital follow-ups and outstanding items in the care plan.

Skills

Motivational interviewing

Panel management

Care coordination

Care plan development

Outreach

Education

High School Diploma or equivalent

Bachelor's or Master's degree in relevant field

CASAC certification

Bachelor’s degree or higher with required experience

NYS Driver's License

Job description

Northwell Health is seeking a Care Management Coordinator to coordinate and participate in Care Management services for families and caregivers. Health Home Plus serves defined populations with SMI enrolled in HHSA, using patient-centered motivational interviewing to build rapport and improve health.

You will support the primary care team by panel management to reduce patients lost to care, and help develop and adjust individualized care plans for high-risk patients addressing medical and social