Care Coordinator, Bilingual

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

📋 Description

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

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

• Confirm eligibility in accordance with Evergreen and payer program criteria.

• Ensure completion of patient consent documentation prior to outreach efforts.

• Maintain patient engagement and identify those who are inactive or not engaged for further escalation.

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

• Meet engagement time standards that align with Medicare CCM billing requirements.

• Reinforce care plans directed by providers during interactions with patients.

• Identify adherence barriers, including issues with medication access, transportation, or social needs.

• Document patient interactions in both the CCM patient management platform and EHR systems.

• Monitor engagement time and maintain documentation that is ready for audits.

• Ensure compliance with HIPAA and PHI regulations.

• Facilitate patient access to referring providers and clinical staff.

• Support care transitions following hospitalizations or emergency department visits.

• Coordinate referrals and follow-up appointments.

• Escalate any symptom concerns or medication issues to licensed clinical staff.

• Utilize CCM and EHR platforms on a daily basis.

• Manage workflows related to patient messaging.

• Collaborate with remote clinical and operational teams.

⛳️ Requirements

• Must be a Certified Medical Assistant.

• Bilingual in Spanish and English.

• 1–3 years of experience in healthcare settings.

• Experience in chronic disease management or nephrology is preferred.

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

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

• Ability to manage a structured, metrics-driven workflow reliably.

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

• Capable of working effectively in a primarily remote work environment.

• Home internet connection must support a minimum download speed of 25 Mbps and an upload speed of 10 Mbps.

• Employees must work from a dedicated space free of ongoing interruptions to safeguard member PHI and HIPAA information.

• Experience in chronic disease management is preferred.

• Prior experience in virtual care, remote nursing, or telehealth programs is preferred.

• Familiarity with CCM regulatory requirements is preferred.

• Strong skills in patient education and motivational interviewing 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.

• A 401(k) program with Evergreen matching up to 4% of contributions after six months of employment.

• Paid parental leave.

• A comprehensive training and development program that begins with onboarding and continues throughout your career at Evergreen Nephrology.

• Eligibility for bonuses.

• Evergreen provides remote employees with telephony applications and equipment to meet the business requirements for their role.