Care Coordinator

This is a fully remote position, open to applicants in United States.

📋 Description

• Provide longitudinal Care Management services through proactive engagement with patients, reviewing charts and care plans, coordinating care, documenting activities, and collaborating with patients, caregivers, providers, and multidisciplinary team members.

• Act as the primary Care Manager for a designated panel of in-office patients or assist patients in Assisted Living Facilities, based on the assignment.

• Identify and enroll eligible patients in suitable Care Management programs and secure necessary consent.

• Conduct thorough patient assessments and determine Care Management needs.

• Create, maintain, and update personalized care plans.

• Review patient charts and care plans to detect status changes, identify care gaps, recognize barriers, and find intervention opportunities.

• Execute proactive outreach to patients and engage in monthly Care Management activities.

• Track patient progress and appropriately escalate clinical concerns or other needs.

• Coordinate care and relay patient updates to providers and interdisciplinary teams.

• Conduct outreach to patients, their family members, caregivers, and Powers of Attorney as necessary.

• Facilitate care coordination among providers, facilities, caregivers, and healthcare team members.

• Document Care Management services, qualifying time, activities, and necessary patient records accurately and promptly.

• Adhere to payer standards, organizational policies, Care Management workflows, and HIPAA regulations.

• Identify social, financial, access, and other barriers to care, connecting patients with internal or community resources.

• Aid in maintaining adherence to care plans, continuity of care, patient outcomes, and ongoing engagement.

• Independently oversee assigned responsibilities, prioritize patient needs, and manage a longitudinal patient population.

• Engage in team meetings, training, and initiatives for Care Management improvement.

• Achieve established productivity, utilization, and performance expectations in Care Management.

⛳️ Requirements

• A background as a Medical Assistant (MA), Licensed Practical Nurse (LPN), or similar clinical healthcare role is highly preferred.

• Prior experience in Care Management, Chronic Care Management (CCM), Advanced Primary Care Management (APCM), population health, or a comparable longitudinal patient-support program.

• Experience within a primary care or ambulatory healthcare setting.

• Familiarity with Athenahealth, ThoroughCare, or similar Electronic Health Record (EHR) and Care Management platforms.

• Understanding of Care Management documentation, time tracking, and payer requirements.

• Bilingual abilities are an advantage.

• Previous experience in healthcare, care coordination, patient support, population health, or a related healthcare environment.

• Excellent verbal and written communication skills.

• Strong organizational and time-management capabilities.

• Ability to independently manage a patient population and multiple ongoing priorities.

• Competence in accurately and consistently documenting patient interactions and Care Management activities.

• Comfortable working with electronic health records, Care Management platforms, and other healthcare technology systems.

• Ability to identify concerns necessitating clinical or operational escalation and communicate these to the appropriate team member.

• Capacity to work effectively and autonomously in a remote setting.

• Consistent availability during designated business hours.

• Compliance with HIPAA regulations and safeguarding patient confidentiality.

🏝️ Benefits

• Fully remote position.

• Reliable internet access for remote work.

• Participation in team meetings, training, and initiatives for Care Management improvement.