Program Coordinator I-Primary Care

Mount Sinai Health System•New York, NY

1d•$66,482 - $75,000

About The Position

The Program Coordinator supports high-quality, patient-centered care by identifying and engaging patients who have outstanding preventive care or chronic disease management needs. Working with physicians, advanced practice providers, nursing, practice operations, and other care-team members, the Coordinator conducts outreach based on provider recommendations and identified quality gaps, and facilitates recommended screenings, laboratory testing, examinations, and follow-up care. The role connects patients with the clinical team by helping them navigate recommended services, addressing barriers to completion, and ensuring appropriate documentation and follow-up. The Coordinator contributes to organizational quality goals, population health initiatives, and improved patient outcomes. The position operates within established clinical protocols and does not independently determine clinical eligibility, recommend treatment, interpret results, or modify care plans. The role supports management of patient registries, work queues, outreach lists, and quality dashboards; tracks patients from identification through care completion or appropriate disposition; and assists with quality improvement, reporting, and outreach initiatives. Performance may be evaluated based on outreach, engagement, care-gap resolution, scheduling and completion rates, documentation, and appropriate escalation, while accounting for factors outside the Coordinator’s control.

Requirements

Bachelor’s degree, or an equivalent combination of education and/or closely related experience that may substitute for the degree.
Strong verbal communication and patient engagement skills.
Ability to communicate effectively with patients from diverse backgrounds.
Strong organizational and follow-up skills, with the ability to manage a high-volume patient outreach worklist.
Attention to detail and commitment to accurate documentation.
Ability to understand and follow standardized clinical and operational workflows.
Ability to recognize issues requiring clinical escalation without providing clinical advice outside the role’s scope.
Proficiency with electronic health records, Microsoft Office, and related healthcare technology.
Ability to collaborate with physicians, advanced practice providers, nurses, medical assistants, scheduling teams, and practice leadership.
Knowledge of HIPAA and patient confidentiality requirements.

Nice To Haves

One to two years of administrative experience preferred; none is required.
Prior experience in an ambulatory medical practice, population health program, patient access center, care coordination, medical office, or healthcare environment.
Experience conducting patient outreach or scheduling healthcare services.
Experience with electronic health records, preferably Epic, and patient work queues.
Working knowledge of preventive health and chronic disease quality measures.

Responsibilities

Conduct proactive outreach to patients identified as having outstanding preventive or condition-specific care needs.
Educate patients about physician-recommended screenings, tests, examinations, and follow-up using approved materials.
Assist patients with scheduling appointments, diagnostic testing, laboratory services, or specialty services; provide scheduling instructions and contact information when direct scheduling is unavailable.
Conduct follow-up outreach for recommended services that have not been completed.
Identify barriers to completing recommended care and escalate issues requiring clinical or operational intervention.
Document outreach, patient responses, scheduled services, refusals, barriers, and other relevant information accurately and promptly in the electronic health record or designated population health platform.
Route clinical questions or concerns to the appropriate licensed clinical team member and remain within the position’s scope.
Support outreach and care coordination for preventive and chronic disease quality measures, including cancer screenings, diabetes monitoring, blood pressure follow-up, depression screening, diabetic eye examinations, kidney health evaluations, and eligible statin therapy follow-up.
Maintain assigned patient registries, work queues, outreach lists, and quality dashboards; prioritize outreach based on organizational goals, clinical guidance, due dates, and identified care gaps.
Review records for services already completed internally or externally before contacting patients, and assist in obtaining outside records when needed.
Facilitate documentation of externally completed services so records and quality reporting accurately reflect completed care.
Track patients from initial identification through completion, documented refusal, clinical exclusion, or appropriate escalation, and maintain accurate care-gap dispositions and outreach activity.
Use patient-centered, courteous, and culturally sensitive communication while protecting patient confidentiality and explaining the basis for outreach.
Connect patients experiencing non-clinical barriers with available resources or the appropriate department, and escalate requests for clinical guidance to nursing or a provider.
Support initiatives to improve preventive screening rates, chronic disease management, and quality performance; monitor outreach activity and completion rates.
Identify recurring barriers, workflow issues, and trends affecting care completion, and communicate operational concerns to practice and program leadership.
Participate in quality improvement initiatives, outreach campaigns, and focused interventions for populations with identified care gaps.
Assist leadership with reports on outreach volume, patient engagement, scheduled and completed services, outstanding care gaps, and other population health metrics.