Care Coordinator, LPN

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

📋 Description

• Perform monthly clinical check-ins and CCM touchpoints for designated patient panels.

• Develop lasting relationships with patients and caregivers through consistent outreach via SMS and phone as necessary.

• Examine patient charts, diagnoses, kidney disease history, medications, lab results, imaging, and treatment cycles prior to calls.

• Clarify CCM participation and emphasize the advantages of the program.

• Conduct structured symptom evaluations and assess changes utilizing licensed clinical judgment.

• Evaluate issues related to medication adherence, side effects, and confusion regarding regimens.

• Identify clinical red flags and escalate urgent matters through established triage pathways.

• Collaborate with healthcare providers and care teams on symptom fluctuations, concerns, and medication-related issues.

• Route EHR messages along with clinically relevant documentation.

• Organize follow-up appointments, lab tests, nephrology consultations, and initiatives to reduce missed care.

• Reinforce CKD and chronic disease management plans and offer symptom-management education within the LPN scope.

• Assist in medication, lifestyle, and follow-up adherence.

• Recognize social, behavioral, or access challenges and coordinate interventions or referrals.

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

• Monitor qualifying CCM time for billing compliance and adhere to regulatory, QA, and partner documentation standards.

• Uphold call quality and adhere to scripting and workflow procedures.

• Maintain or exceed 80% monthly engagement and a 90% billable conversion rate.

• Engage in peer reviews, QA audits, coaching, and ongoing education.

• Relay recurring patient necessities and trends to the Program Manager.

• Carry out other duties pertinent to the role as assigned.

⛳️ Requirements

• Valid California LPN or Licensed Vocational Nurse (LVN) license.

• At least 1–2 years of clinical experience in ambulatory care, population health, care coordination, or case management.

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

• Proficient in working with two systems concurrently: EHR and CCM platform.

• Capacity to manage a structured, metric-driven workflow with dependability.

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

• Ability to operate effectively in a predominantly remote environment.

• Home internet must support a minimum of 25 Mbps download and 10 Mbps upload; cable, fiber, or DSL hardwired connections are preferred.

• Designated workspace free from ongoing interruptions to safeguard member PHI/HIPAA information.

• Preferred: experience in chronic disease management.

• Preferred: bilingual in Spanish and English.

• Preferred: previous experience in virtual care, remote nursing, or telehealth programs.

• Preferred: familiarity with CCM regulatory standards.

• Preferred: strong skills in patient education and motivational interviewing.

🏝️ Benefits

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

• 12 paid holidays annually.

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

• Reimbursement for continuing medical education for eligible positions.

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

• Paid parental leave.

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

• Quarterly bonus opportunities.

• Remote employees will receive telephony applications and equipment to fulfill business requirements.