Program Coordinator I-Primary Care

Mount Sinai Health System•New York, NY

About The Position

The Program Coordinator supports high-quality, patient-centered care by identifying and engaging patients with outstanding preventive care and 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 care gaps. The role helps patients complete recommended screenings, laboratory testing, examinations, and follow-up care; navigate services; address barriers; and ensure appropriate documentation and follow-up. The position contributes to organizational quality goals, population health initiatives, and improved patient outcomes. The Coordinator manages assigned patient registries, work queues, outreach lists, and quality dashboards, tracking patients from initial identification through service completion, documented refusal, clinical exclusion, or appropriate escalation. The Coordinator follows established protocols and recommendations and does not independently determine clinical eligibility, recommend treatment, interpret results, or modify care plans. Clinical questions and concerns are routed to licensed clinical team members. The role supports quality improvement and reporting by monitoring outreach activity and completion rates, identifying recurring barriers and workflow issues, communicating trends to leadership, and assisting with reports on outreach, patient engagement, scheduled and completed services, outstanding care gaps, and other population health metrics. Performance may be evaluated using outreach, care-gap, scheduling, completion, documentation, escalation, and patient service measures, while accounting for factors outside the Coordinator’s control.

Requirements

Bachelor’s degree, or an equivalent combination of education and/or closely related experience.
Strong verbal communication and patient engagement skills, including the ability to communicate effectively with patients from diverse backgrounds.
Strong organizational and follow-up skills and 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 identify 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.
Experience in an ambulatory medical practice, population health program, patient access center, care coordination, medical office, or other healthcare environment.
Experience conducting patient outreach or scheduling healthcare services.
Experience using 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, laboratory testing, examinations, and follow-up appointments using approved materials.
Assist patients with scheduling appointments, diagnostic testing, laboratory services, or specialty services, and provide scheduling instructions when direct scheduling is unavailable.
Follow up with patients when recommended services have not been completed.
Identify barriers to completing care and escalate issues to the appropriate clinical or operational team.
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 work within the position’s scope.
Support outreach and care coordination for quality measures, including cancer screenings, diabetes monitoring, blood pressure follow-up, depression screening, diabetic eye examinations, kidney health evaluations, statin therapy follow-up, and other organizationally identified measures.
Maintain assigned patient registries, work queues, outreach lists, and quality dashboards; prioritize outreach based on organizational goals, clinical guidance, due dates, and care gaps.
Review available records for services completed internally or externally, assist with obtaining outside records, and facilitate documentation of external services.
Track patients through the outreach process and maintain accurate care-gap and outreach dispositions.
Use patient-centered, courteous, and culturally sensitive communication while protecting patient confidentiality.
Connect patients experiencing non-clinical barriers with available resources or the appropriate department.
Support quality improvement initiatives, outreach campaigns, and focused interventions for populations with identified care gaps.
Monitor outreach activity and completion rates, identify trends and workflow concerns, and communicate them to practice and program leadership.
Assist leadership with reporting on outreach volume, patient engagement, scheduled and completed services, outstanding care gaps, and other population health metrics.