Integrated Care Coordinator (ICC)

Title: Integrated Care Coordinator (ICC)

Location: Brooklyn, New York, United States

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)

Consistent with the Care Management Division's integrated model, ICCs may also be assigned to support patients in additional care management programs offered through Essen Health Care. These assignments are made based on the coordinator's qualifications, experience, and program need, and include activities such as:

• 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

• 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)