Integrated Care Coordinator (ICC)

Overview Company Overview: Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents. Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it. We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community. Job Summary Position Title: Integrated Care Coordinator Position Summary: Essen Health Care's Care Management Division is seeking an Integrated Care Coordinator (ICC) to provide comprehensive care coordination services to patients with complex chronic conditions, including those enrolled in the New York State Health Home program. The ICC is a core member of Essen's care management team, responsible for ensuring that high-need patients receive coordinated, whole-person care across medical, behavioral health, and social service systems. As Essen continues to expand its Care Management Division, ICCs may support additional evidence-based care management programs within the division, consistent with their qualifications and the needs of the organization. Responsibilities Health Home — Complex Care Management (Primary) Manage an active caseload of patients enrolled in the New York State Health Home program, with a focus on homebound and medically complex individuals Conduct comprehensive assessments and develop individualized care plans that address medical, behavioral health, housing, and social determinants of health Provide regular outreach, monitoring, and follow-up to ensure care plan implementation and patient engagement Coordinate across primary care, specialty care, behavioral health providers, and community-based organizations to close gaps in care Maintain timely, accurate documentation in compliance with NYSDOH Health Home program standards Participate in care team meetings, case conferences, and quality improvement activities Support patients in navigating insurance, benefits, and community resources Care Management Program Support (As Assigned) Chronic disease monitoring and patient engagement under Medicare and Medicaid care management programs Preventive care outreach and care gap closure for primary care patient populations Care transition support, including scheduling coordination and documentation for patients moving between care settings Patient enrollment and onboarding for care management program participants Qualifications Required Bachelor's degree in Social Work, Nursing, Public Health, Health Education, or a related field — or equivalent professional experience Minimum 1–2 years of experience in care management, case management, or healthcare coordination Knowledge of the New York State Health Home program, Medicaid managed care, or community-based care services Strong patient communication skills with demonstrated ability to engage medically complex or vulnerable populations Ability to manage a patient caseload with organized documentation and consistent follow-through Proficiency with electronic health records (EHR) and care management platforms Preferred Active clinical or care management credential: LMSW, RN, LPN, CHW, or equivalent Experience with chronic disease management, behavioral health integration, or homebound patient populations Bilingual in Spanish, Mandarin, Cantonese, or another language serving Essen's patient communities Familiarity with Medicare and Medicaid care management programs including CCM, BHI, RPM, or APCM Background in patient outreach, enrollment, or community health work Compensation & Benefits Pay: $20.00 - $25.00 per hour Job Type: Full-time Remote & Hybrid opportunities available (Subject to change) Equal Opportunity Employer Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population. #J-18808-Ljbffr Essen Medical Associates