Program Coordinator I-Primary Care

The Program Coordinator supports the delivery of high-quality, patient-centered care by proactively identifying and engaging patients with outstanding preventive care and chronic disease management needs.

Working in collaboration with physicians, advanced practice providers, nursing, practice operations, and other members of the care team, the Program Coordinator conducts outreach to patients based on provider recommendations and identified quality care gaps. The Coordinator facilitates completion of recommended screenings, laboratory testing, examinations, and follow-up care.

The role serves as an important link between patients and the clinical team, helping patients navigate recommended services, addressing barriers to completion, and ensuring appropriate documentation and follow-up. The Program Coordinator contributes directly to organizational quality goals, population health initiatives, and improved patient outcomes.

Patient Outreach & Care Coordination

• Conduct proactive outreach to patients identified by physicians, clinical teams, quality reports, registries, or population health worklists as having outstanding preventive or condition-specific care needs.
• Educate patients regarding the importance of completing physician-recommended screenings, laboratory testing, examinations, and follow-up appointments using approved patient education and communication materials.
• Assist patients with scheduling appropriate appointments, diagnostic testing, laboratory services, or specialty services.
• Provide patients with appropriate scheduling instructions and contact information when direct scheduling is not available.
• Conduct follow-up outreach when recommended services have not been completed.
• Identify barriers that may prevent patients from completing recommended care and escalate issues to the appropriate clinical or operational team when additional intervention is required.
• Document all patient outreach, responses, scheduled services, refusals, barriers, and other relevant information accurately and timely 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 defined scope of the position.

  Quality & Care Gap Management

• Support outreach and care coordination for quality measures and preventive/chronic disease care gaps, including but not limited to:
• Breast cancer screening/mammography
• Colorectal cancer screening/colonoscopy and other approved screening modalities
• Diabetes monitoring, including HbA1c testing
• Blood pressure monitoring and follow-up for patients with hypertension
• Depression screening and appropriate clinical follow-up workflows
• Diabetic eye examinations
• Kidney health evaluation for patients with diabetes
• Statin therapy and related follow-up for eligible patients
• Other preventive health, chronic disease, and quality measures identified by the organization, payer programs, or clinical leadership

• The Coordinator does not independently determine clinical eligibility, recommend treatment, interpret results, or modify a patient's care plan. Outreach is conducted according to established clinical protocols, quality criteria, and/or physician or care-team recommendations.

  Program Worklist Management

• 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 available records to determine whether recommended services may have already been completed internally or externally before contacting the patient.
• Assist with obtaining outside records when patients report that screenings, examinations, or testing were completed outside the health system.
• Facilitate appropriate documentation of externally completed services so that patient records and quality reporting accurately reflect completed care.
• Track patients through the outreach process from initial identification through completion, documented refusal, clinical exclusion, or appropriate escalation.

• Maintain accurate disposition of assigned care gaps and outreach activity.

  Patient Engagement

• Use patient-centered communication techniques to encourage participation in preventive and chronic disease care.
• Explain the purpose of outreach clearly while reinforcing that recommendations originate from the patient's physician, care team, or established clinical protocols.
• Provide courteous and culturally sensitive service while maintaining patient confidentiality.
• Recognize when a patient requires additional clinical guidance and appropriately escalate to nursing or the provider.

• Support patients experiencing non-clinical barriers to completing care by connecting them with available resources or the appropriate department.

  Quality Improvement & Reporting

• Support departmental initiatives designed to improve preventive screening rates, chronic disease management, and overall quality performance.
• Monitor assigned outreach activity and completion rates.
• Identify recurring barriers, workflow issues, or trends affecting patients' ability to complete recommended care.
• Communicate trends and 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 related to outreach volume, patient engagement, scheduled services, completed services, outstanding care gaps, and other population health metrics.

  Performance Expectations

• Performance may be evaluated using measures such as:
• Number of patients successfully contacted
• Outreach completion rate
• Percentage of identified care gaps addressed
• Screening/test scheduling conversion
• Completion rate following outreach
• Accuracy and timeliness of documentation
• Reduction in outstanding care gaps
• Appropriate escalation of clinical concerns
• Patient engagement and service quality
• Performance expectations should account for patient eligibility, inability to contact patients, patient refusal, clinical exclusions, and other factors outside of the Coordinator's control.

• Bachelor's Degree or an equivalent combination of education and/or experience may substitute for the degree when the experiences are closely related to the duties of the job.
• None required, but 1-2 years administrative experience preferred

Experience:

• Prior experience in an ambulatory medical practice, population health program, patient access center, care coordination, medical office, or healthcare environment preferred.
• Experience conducting patient outreach or scheduling healthcare services strongly preferred.
• Experience working with electronic health records, preferably Epic, and patient work queues preferred.

Knowledge, Skills & Abilities

• 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 scope of the role.
• Working knowledge of preventive health and chronic disease quality measures preferred.
• Proficiency with electronic health records, Microsoft Office, and related healthcare technology.
• Ability to work collaboratively with physicians, APPs, nurses, medical assistants, scheduling teams, and practice leadership.

• Knowledge of HIPAA and patient confidentiality requirements.

Compensation Statement

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $66,482.07 - $75,000.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Non-Bargaining Unit, 077 - Primary Care MSH - ISM, Icahn School of Medicine