Job Description Coordinates and participates in activities related to Care Management services to family members and caregivers. 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. * Health home or care management experience strongly preferred. * NYS Driver's License strongly preferred. * 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).