The coordinator manages care for patients with severe mental illness by developing individualized care plans and facilitating communication between providers. They also perform outreach activities and track high-risk populations to ensure continuity of care and adherence to treatment plans.
Coordinates and participates in activities related to Care Management services to family members and caregivers. Health Home Plus is an intensive Health Home care management service established for defined populations with SMI (severe mental illness) who are enrolled in HHSA.
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
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 Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) 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: Putnam, Dutchess and Ulster County
*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).
Candidates must have a high school diploma and 1-3 years of relevant experience, though a bachelor's or master's degree is strongly preferred. Specific experience with the SMI or SED population or a CASAC credential is highly desired.
Market context
In New York, physician openings are often shaped by steady patient demand and the need for clinicians who can work within complex care settings. These roles are competitive because employers typically look for strong clinical credentials, relevant state licensure, and experience that matches the specialty. Review the AI-summarized requirements and benefits on this platform to quickly confirm fit, then verify the original posting for any details that affect your application.
