Health Home Care Navigator for High-Risk Patients

Northwell Health; Manhasset (NY); On-site; USD 60,000 - 75,000; Full time

Job summary

Northwell Health in New York is seeking a Care Management professional to coordinate services for families and caregivers within Health Home Plus for defined populations with SMI. The role emphasizes motivational interviewing and proactive care planning to keep patients engaged in services.

The position involves collaborating with primary care teams, hospitals, and community resources to ensure seamless transitions and timely follow-up, with outreach across clinics, homes, and neighborhoods to

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 in ANY field with either: three (3) years of experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population, highly preferred.
• NYS Driver's License strongly preferred.
• Location: Staten Island.

Responsibilities

• Uses 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.
• Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources on behalf of patients 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 any outstanding items identified in the patient's care plan. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.

Education

High School Diploma or equivalent

1-3 years of relevant experience

Bachelor's or Master's degree strongly preferred

CASAC and two years experience OR Bachelor's with 3 years experience in health home care management

NYS Driver's License strongly preferred

Job description

Northwell Health in New York is seeking a Care Management professional to coordinate services for families and caregivers within Health Home Plus for defined populations with SMI. The role emphasizes motivational interviewing and proactive care planning to keep patients engaged in services.

The position involves collaborating with primary care teams, hospitals, and community resources to ensure seamless transitions and timely follow-up, with outreach across clinics, homes, and neighborhoods to