Patient-Centered Care Coordination Specialist

Northwell; Melville (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

Northwell is seeking a Care Manager to coordinate and participate in Care Management services for patients and their families. The role emphasizes patient-centered motivational interviewing to build rapport and improve health outcomes.

The position supports the primary care team by managing panels, developing individualized care plans, and addressing medical and social barriers for high-risk patients. Strong collaboration with hospitals, PCPs, and community resources is essential.

Qualifications

• 1-3 years of relevant experience, required.
• High School Diploma or equivalent required.
• Bachelor's or Master’s degree in relevant field strongly preferred.
• Health home or care management experience strongly preferred.
• NYS Driver's license strongly preferred.
• Bilingual Spanish preferred.

Responsibilities

• Coordinates and participates in activities related to Care Management services to family members and caregivers.
• 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 patient's care plan. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.

Skills

Motivational interviewing

Care coordination

Bilingual Spanish

Education

High School Diploma or equivalent

Bachelor's or Master’s degree in relevant field

Job description

Northwell is seeking a Care Manager to coordinate and participate in Care Management services for patients and their families. The role emphasizes patient-centered motivational interviewing to build rapport and improve health outcomes.

The position supports the primary care team by managing panels, developing individualized care plans, and addressing medical and social barriers for high-risk patients. Strong collaboration with hospitals, PCPs, and community resources is essential.