Patient-Centered Care Coordination Specialist

Northwell Health; Manhasset (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

Northwell Health in New York seeks a Care Management professional to coordinate services for patients and families, building rapport using motivational interviewing and contributing to individualized care plans across medical and social barriers.

The role supports primary care teams, tracks high-risk populations, and liaises with hospitals, specialists, and community resources to ensure continuity of care in diverse settings.

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience, required.
• Bachelor27s or Master27s degree in relevant field strongly preferred.
• Health home or care management experience strongly preferred.
• NYS Driver27s License strongly preferred.
• Bilingual Spanish, 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 that address both medical and social barriers to accessing 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 patients care plan. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.

Skills

Motivational interviewing

Care coordination

Panel management

Bilingual Spanish

Education

High School Diploma

Bachelor27s or Master27s degree in relevant field

Job description

Northwell Health in New York seeks a Care Management professional to coordinate services for patients and families, building rapport using motivational interviewing and contributing to individualized care plans across medical and social barriers.

The role supports primary care teams, tracks high-risk populations, and liaises with hospitals, specialists, and community resources to ensure continuity of care in diverse settings.