FQHC Enhanced Care Manager

Job Function Summary: Involves providing non-clinical support, guidance and assistance for patients and families as they navigate through complex healthcare environments. Primary goals are to increase patient satisfaction, and to optimize care and outcomes. Acts as a communication liaison to understand the patient's non-clinical individual needs, desires, and concerns. Guides the patient and family to a broad range of services, amenities, and information to promote healing and ensure satisfaction with the patient care experience. Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions. Serves as a non-clinical resource and liaison for patients and their families. Assists with navigating all aspects of the healthcare system. Uses knowledge of the unit or clinic to resolve issues and identify ways to increase patient satisfaction. Collaborates with department managers to meet patient expectations, achieve quality outcomes and build a patient focused culture. % of time Essential Function (Yes/No ) Key Responsibilities (To be completed by Supervisor) 30 Core Responsibilities Patient Outreach & Engagement Provide ongoing care management and health coaching support for patients enrolled in disease management and care coordination programs. Health Education & Self-Management Support Resource Connection & Barrier Resolution Documentation & Information Management Collaboration & Team-Based Care Quality & Professional Practice 25 Care Gap Closure/Care Coordination Conduct high-volume telephonic and occasional in-person outreach to engage patients in preventive care and disease management programs. Support closure of care gaps, CMS quality measures, and value-based care initiatives. Assess patient needs and facilitate scheduling of preventive and follow-up services. Build rapport with patients and caregivers to improve engagement and participation in care. Provide patient education regarding preventive care, screenings, immunizations, and chronic disease management. Collaborate with interdisciplinary teams to improve patient outcomes and organizational quality performance. 15 Longitudinal Care Management Provide ongoing care management and health coaching support for patients enrolled in disease management and care coordination programs. Utilize Motivational Interviewing techniques to promote behavior change and support self-management. Reinforce provider-directed care plans and patient health goals. Monitor patient progress, identify barriers to care, and facilitate problem-solving. Provide education and support related to chronic conditions, medications, lifestyle modifications, and self-management strategies . 15 Care Coordination & Patient Navigation Coordinate care across providers, clinics, departments, and community organizations. Assist patients with appointment scheduling, reminders, transportation, medication access, and referrals. Support transitions of care and continuity across healthcare settings. Triage patient questions and facilitate resolution of administrative, financial, and clinical concerns. Serve as a liaison between patients, caregivers, providers, and care teams 10