Health Home Care Navigator for High‑Risk Patients

Northwell Health; Suffolk (MS); On-site; USD 65,000 - 90,000; Full time

Job summary

Northwell Health is seeking a Care Management Associate to support Health Home Plus services for defined populations in Putnam, Dutchess, and Ulster counties. Responsibilities include patient-centered outreach, coordination with primary and specialty care, and development of individualized care plans for high-risk individuals.

The role emphasizes collaboration with hospitals, PCPs, and community resources to improve access and adherence to care, while tracking high-risk patients and ensuring

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience required.
• Bachelor's or Master's degree in a relevant field strongly preferred.
• CASAC plus 2 years experience OR Bachelor's with 3 years health home care management experience preferred.
• NYS Driver's License strongly preferred.

Responsibilities

• Use motivational interviewing to build rapport and improve health.
• Provide panel management to reduce care loss and support care plans for high-risk patients.
• Coordinate with hospitals, PCPs, specialists, and community resources.
• Identify high-risk groups and patients due for preventive or chronic care services.
• Track discharged patients and ensure follow-ups.
• Close the loop on referrals and outreach in care sites, homes, and neighborhoods.

Skills

Motivational interviewing

Panel management

Care coordination

Liaison with hospitals/ PCPs

Team-based communication

Outreach in clinics/homes

Education

High School Diploma or equivalent

Bachelor's degree in relevant field

Master's degree in relevant field (preferred)

CASAC certification with 2 years experience or higher (preferred)

Job description

Northwell Health is seeking a Care Management Associate to support Health Home Plus services for defined populations in Putnam, Dutchess, and Ulster counties. Responsibilities include patient-centered outreach, coordination with primary and specialty care, and development of individualized care plans for high-risk individuals.

The role emphasizes collaboration with hospitals, PCPs, and community resources to improve access and adherence to care, while tracking high-risk patients and ensuring