Care Coordinator

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

📋 Description

• Provide proactive care coordination for patients dealing with complex chronic conditions such as CKD, hypertension, diabetes, cardiovascular disease, and associated comorbidities.

• Assist in the enrollment and onboarding process for CCM patients.

• Verify patient eligibility in accordance with Evergreen and payer program criteria.

• Complete consent documentation prior to patient outreach.

• Maintain ongoing patient engagement and address inactive or unresponsive patients.

• Conduct weekly outreach via text and telephone to enrolled CCM patients.

• Adhere to engagement time standards in line with Medicare CCM billing requirements.

• Reinforce care plans directed by providers.

• Identify adherence barriers, including medication access, transportation, and social needs.

• Make a high volume of outbound calls and texts, and perform follow-up outreach.

• Record patient interactions in CCM management and EHR systems.

• Monitor engagement time and maintain documentation ready for audit.

• Ensure compliance with HIPAA and PHI standards.

• Assist in facilitating access to referring providers and clinical staff.

• Support care transitions following hospitalizations or emergency department visits.

• Coordinate referrals and follow-up appointments.

• Elevate symptom concerns or medication issues to licensed clinical personnel.

• Utilize CCM platforms and EHR systems on a daily basis.

• Manage patient messaging workflows efficiently.

• Collaborate with remote clinical and operational teams.

⛳️ Requirements

• Certified Medical Assistant.

• Bilingual in Spanish and English.

• 1–3 years of experience in healthcare.

• Strong skills in clinical assessment, communication, and documentation.

• Comfortable working simultaneously within two systems (EHR and CCM platform).

• Ability to manage a structured, metric-driven workflow consistently.

• Intermediate proficiency in MS Office Suite, including Outlook and Teams.

• Home internet connection with a minimum download speed of 25 Mbps and upload speed of 10 Mbps.

• A dedicated workspace free from interruptions to ensure the protection of PHI/HIPAA information.

• Availability to work from 8:00 am to 5:00 pm Pacific Time.

• Preferred experience in chronic disease or nephrology.

• Preferred background in chronic disease management, virtual care, remote nursing, or telehealth programs.

• Familiarity with CCM regulatory requirements is preferred.

• Strong patient education and motivational interviewing skills are preferred.

🏝️ Benefits

• Paid time off starting at 4 weeks for full-time employees.

• 12 paid holidays each year.

• Medical, dental, vision, and life insurance, including an HSA with employer matching.

• Reimbursement for continuing medical education for eligible positions.

• 401(k) plan with Evergreen matching up to 4% of contributions after six months of service.

• Paid parental leave.

• Comprehensive training and development program from onboarding through your career.

• Eligibility for bonuses.

• Telephony applications and equipment provided for remote employees.