Coordinates and participates in activities related to Care Management services to family members and caregivers. Northwell Health's Health Home Serving Children is a New York State Medicaid care coordination program that provides access to medical, mental health, substance abuse, social support services, and family support services to children who need them. Health Home services are free to those who qualify. This role is hybrid and involves field work.

**This position will be based on Suffolk, Nassau, Queens, Staten Island, NYC and Brooklyn.

Job Responsibility

• 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.

Job Qualification

• Bachelor's degree or Master's in social work or a relevant field strongly preferred.
• 2 years' experience Home Health or care management experience strongly preferred.
• NYS Driver's License strongly preferred.
• High School Diploma or equivalent required.
• One to three (1-3) years of relevant experience, required.
• Positions available in all counties in the city and long island.
• Hours are Hybrid M-F 9-5 with some flexibility and one evening per week needed

*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).