Care Coordinator

SB Clinical Practice Management•Town of Brookhaven, NY

8d•$22 - $27•Onsite

About The Position

The Care Coordinator is responsible for providing care coordination services to patients who require enhanced support across medical, behavioral, and social domains. Working closely with a multidisciplinary care team, the Care Coordinator ensures timely access to high-quality care, supports self-management goals, and facilitates referrals to both internal and community-based resources. The Care Coordinator also serves as a liaison and advocate for patients navigating the health care system, promoting continuity and improved health outcomes.

Requirements

High school diploma/GED.
Three years of experience working in an office setting.
Must be proficient in MS Word and knowledge of Excel.
Must be proficient in arranging meetings on Teams and Zoom.
Strong organizational, analytical, and problem-solving abilities.
Ability to work collaboratively as part of an interdisciplinary team.

Nice To Haves

Experience working in integrated medical health care settings.
Familiarity with community resources, entitlement programs, and patient navigation strategies.
Local knowledge of health and social services available on Long Island and/or the surrounding region.
Bilingual (English/Spanish or other relevant language) preferred.

Responsibilities

Support the care management team in identifying and engaging patients in need of enhanced care coordination services.
Collaborate with providers and clinical teams to assess patient needs, develop care plans, and link patients to appropriate community, behavioral health, and social service resources.
Track patient activity across the care continuum, including emergency department visits, hospital admissions, and discharges.
Conduct follow-up outreach within designated timeframes following hospital or emergency room encounters to support care transitions.
Assist patients with eligibility and enrollment in pharmaceutical assistance programs and other benefit services as needed.
Coordinate referrals to medical and specialty providers and ensure follow-up and integration of referral information into the patient’s care plan.
Work collaboratively with primary care, behavioral health, and specialty teams to ensure continuity of care and information-sharing across settings.
Cultivate and maintain relationships with external service providers and community organizations.
Maintain timely and accurate documentation in the EHR, in accordance with organizational policies.
Actively monitor and respond to messages in designated message pools.
Ensure timely and accurate management of all communications within assigned electronic message pools.
Participate in quality improvement initiatives, data collection, and reporting related to care coordination outcomes.
The Care Coordinator facilitates seamless patient care by arranging and tracking referrals, tests, and treatment plans
Assists the care manager and care coordination team in delivering effective chronic disease management
Maintains up-to-date records in the EMR
Serves as a communication link between patients, families, and the healthcare team to ensure coordinated, patient-focused care.
Perform other duties as assigned by leadership.