Care Management Coordinator in Marshfield, Wisconsin at Family Health Center of M

JOB SUMMARY

** This is a hybrid position. Ideal candidate to be located within an hour from Family Health Center in Marshfield. **

The Care Management Coordinator supports patients/families in navigating the healthcare system by coordinating services, facilitating communication between patients and providers, and assisting with access to community and healthcare resources. This role promotes continuity of care, enhances patient engagement, and improves health outcomes through proactive outreach, education, and care coordination.

ESSENTIAL JOB FUNCTIONS

1. Conducts outreach to patients/families to promote access to primary care, preventive services, and community resources.
2. Assists patients/families in navigating the healthcare system, including scheduling appointments, understanding referrals, and connecting with support services.
3. Builds trusting relationships with patients/families to support engagement in care and adherence to treatment plans.
4. Identifies barriers to care (e.g. transportation, insurance, food insecurity, housing) and connects patients/families to appropriate community and social service resources.
5. Provides culturally appropriate health education on topics such as chronic disease management, preventive health, medication adherence, and wellness.
6. Supports care management staff and clinical teams by providing follow-up calls, and coordination as directed.
7. Documents patient interactions, services provided, and outcomes in the electronic health record (EHR) or other designated systems in a timely and accurate manner.
8. Participates in multidisciplinary team meetings and case conferences to coordinate care and share information on patient needs.
9. Maintains confidentiality and professional boundaries while fostering patient empowerment and self-advocacy.
10. Participates in continuing education, training, and quality improvement initiatives related to population health and community resources.
11. Processes and tracks incoming and outgoing referrals
12. Maintains strict adherence to scheduled work hours with regular and reliable attendance.
13. Performs other duties as assigned.