Program Coordinator I-Primary Care

Mount Sinai Health Systems•New York, NY

2d•$66,482 - $75,000

About The Position

The Program Coordinator supports high-quality, patient-centered primary 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, and helps patients complete recommended screenings, laboratory testing, examinations, and follow-up care. The role connects patients with the clinical team, helps them navigate recommended services, addresses non-clinical barriers, and ensures appropriate documentation and follow-up. The Coordinator contributes to organizational quality goals, population health initiatives, and improved patient outcomes. The position follows established clinical protocols and remains within its defined scope: it does not independently determine clinical eligibility, recommend treatment, interpret results, or modify care plans. The Coordinator manages patient registries, work queues, outreach lists, and quality dashboards; tracks patients through outreach and care-gap resolution; supports quality-improvement efforts and reporting; and escalates clinical questions or concerns to licensed clinical staff. Performance may be evaluated through outreach, engagement, scheduling, care-gap completion, documentation, and service-quality measures, taking account of 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.
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 preferred; no experience is required.
Experience in an ambulatory medical practice, population health program, patient access center, care coordination, medical office, or other healthcare environment preferred.
Experience conducting patient outreach or scheduling healthcare services strongly preferred.
Experience with electronic health records, preferably Epic, and patient work queues preferred.
Working knowledge of preventive health and chronic disease quality measures preferred.

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, and specialty services; provide instructions and contact information when direct scheduling is unavailable.
Follow up with patients when recommended services have not been completed.
Identify barriers to completing recommended care and escalate issues requiring clinical or operational intervention.
Document outreach, 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 and concerns to the appropriate licensed clinical team member and work within the defined scope of the position.
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 according to organizational goals, clinical guidance, due dates, and identified care gaps.
Review available records for services completed internally or externally before contacting patients.
Assist in obtaining outside records and documenting externally completed services so records and quality reporting reflect completed care.
Track patients from initial identification through service completion, documented refusal, clinical exclusion, or appropriate escalation, and maintain accurate care-gap dispositions.
Use patient-centered, courteous, and culturally sensitive communication while maintaining confidentiality and explaining that recommendations come from the patient's physician, care team, or established protocols.
Connect patients experiencing non-clinical barriers with available resources or the appropriate department.
Support initiatives to improve preventive screening rates, chronic disease management, and overall quality performance.
Monitor outreach activity and completion rates; identify recurring barriers, workflow issues, and trends; and communicate operational concerns to practice and program leadership.
Participate in quality-improvement initiatives, outreach campaigns, and focused interventions for populations with care gaps.
Assist leadership with reports on outreach volume, patient engagement, scheduled and completed services, outstanding care gaps, and other population health metrics.