Description:
The Field Care Coordinator plays a critical role in bringing care directly to our members where they are, both at home and in the community. This role focuses on hands-on, relationship-based support through in-person visits, new patient onboardings, and field-based outreach. Field Care Coordinators help members overcome barriers to care by assisting with everything from care plan follow-up and blood pressure checks to grocery or care package drop-offs.
What You'll Do
- Serve as the primary point of contact for members with complex medical, behavioral, and social needs
- Meet members in person at their homes, in the community, or at partner organizations to complete new patient onboardings, deliver care packages, or collect health readings such as blood pressure
- Conduct in-person visits to assess member needs, provide ongoing support, and encourage adherence to care plans
- Coordinate services, appointments, and referrals across primary care, behavioral health, and social support resources
- Support care continuity by collaborating with internal care team members including Nurses and Behavioral Health Care Managers
- Identify and address barriers to care such as transportation, medication access, or health literacy challenges
- Develop and maintain individualized care plans and ensure follow-up on all interventions and goals
- Maintain accurate and timely documentation of all member interactions and care coordination activities
- Advocate for member needs within the healthcare and social support systems
- Participate in collaborative care meetings with other members of the care team to review patient panels, discuss progress, and align on care plans
What You'll Need
- Bilingual – English/Spanish
- 1+ years of field based (in person) case management or care coordination
- Physical location in or near Alameda County with familiarity of the local community and resources
- Reliable transportation for regular field visits, including patient homes, clinics, community-based organizations, and partner sites
- Valid driver's license and current auto liability insurance
- Strong understanding of cultural fluency and the ability to build trust with diverse populations
- High degree of empathy and ability to remain patient when faced with adversity
- Demonstrated ability to work collaboratively in a multidisciplinary care team
- Excellent organizational skills and attention to detail
- Strong technical skills and comfort learning new systems; experience with tools such as Google Suite, Slack, CRM databases, and basic Excel, Word, email, and video conferencing
- Reliable, HIPAA-compliant workspace with a stable internet connection for documentation and team communication