The Care Coordinator is responsible for coordinating care and guidance to primarily at-risk patients from diagnosis to survivorship. Uses evidence based research to formulate the plan of care and ensure that patients at risk are following their protocols. Documents outcomes and maintains database of patient QI initiatives and outcomes. Coordinates the appropriate resources and consult services to provide continuity of care and appropriate follow up plan of care. Communicates with all members of the healthcare team. Initiates appropriate patient teaching based on needs. Supports the patient in decision making, may assist in coordination of end of life care if necessary. Develops effective interpersonal relationships with patients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources, electronic medical record and Centers for Medicare and Medicaid data to educate patients and form a care plan with specific health outcomes.

Responsibilities

• Provides guidance for patients from diagnosis to survivorship. Patients at risk are referred to the Care Coordinator to ensure that patient receives comprehensive and quality care with appropriate follow up.
• Initiates and documents patient interventions and referrals for data analysis. Uses evidence based research to assist in care plan and to provide external parties with information regarding patient data.
• May coordinate and assist patients to overcome any obstacles that may inhibit their care plan such as child care and transportation.
• Document all initiatives with patients in database so can quantify for both QI initiatives and internal documentation support.
• May work with Patient Navigators to ensure that benchmarks are met and reporting is completed in a thorough and timely fashion.
• May supervise a team of Patient Navigators via chart review, face-to-face case discussions and performance reviews.
• May work closely with MSH Security and New York City Police in any emergency situation where patient is not communicating or attending their treatment sessions.
• Initiates and documents patient teaching based on assessment of needs
• Partners with families and patient care team and community resources to provide well-coordinated timely compassionate, exemplary, interdisciplinary care.
• Initiates and performs ongoing review of policies related to services provided. Troubleshoots and updates as necessary.
• Serves as resource for community based education, screening, symposiums, educational sessions, lectures, staff training, etc.

Qualifications

• Bachelors degree in Health Sciences, Social Work or other professional degree.
• 1-3 years relevant experience in patient navigation preferred. Population specific experience very important. Excellent verbal and written communication skills to communicate effectively with patients, staff, visitors and vendors.
• Ability to speak Spanish desirable

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.