Bilingual Field Care Coordinator / Field Case Management

About the role

Pair Team is expanding its partnership with one of our largest health plan partners through an exciting new field-based care management role focused on improving patient engagement and access to care throughout Alameda County. The Field Care Coordinator plays a critical role in bringing care directly to patients where they are—at home and in the community. This is a highly active, relationship-based role focused on hands-on support, in-person outreach, new patient onboarding, and helping patients overcome barriers to accessing care. You may support patients with a wide range of needs, including care plan follow-up, blood pressure checks, connecting patients to resources, and delivering groceries or care packages when needed. High-Volume Field-Based Care Management This is a fast-paced, high-volume role supporting a large and complex patient population across Alameda County. Field Care Coordinators are expected to be in the community five days per week, meeting patients where they are and managing a busy daily field schedule. The average monthly expectation is approximately 120 completed in-person patient visits per month, or roughly 30 visits per week. Success in this role requires strong organization, time management, independence, and the ability to efficiently manage a high volume of patient interactions while adapting to changing needs in the field.

Responsibilities

• Manage a high-volume, field-based caseload and complete approximately 30 in-person patient visits per week (up to 120 visits per month).
• Independently manage a busy daily schedule while traveling throughout Alameda County to meet patients where they are.
• Support recurring community-based events and provide care coordination for patients with complex needs.
• 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.

Requirements

• Bilingual