Care Coordinator, LPN

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

📋 Description

• Conduct monthly touchpoints for assigned patient panels through Chronic Care Management (CCM).

• Foster ongoing relationships with patients and their caregivers via regular outreach efforts.

• Review patient chart data prior to calls, including diagnoses, kidney disease history, medications, labs, imaging, and treatment cycles.

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

• Perform structured symptom assessments and evaluate changes using licensed clinical judgment.

• Address medication adherence issues, side effects, or confusion regarding treatment regimens.

• Identify clinical red flags and elevate urgent matters according to triage protocols.

• Collaborate with provider teams on symptom changes, concerns, and medication-related issues.

• Route messages in the Electronic Health Record (EHR) with clinically pertinent documentation.

• Coordinate follow-up scheduling, laboratories, nephrology appointments, and initiatives to minimize missed care.

• Reinforce care plans for Chronic Kidney Disease (CKD) and other chronic conditions.

• Provide symptom management instructions within the scope of Licensed Practical Nurse (LPN) practice.

• Support adherence to medications, lifestyle changes, and follow-up appointments.

• Identify social, behavioral, or access-related barriers and recommend appropriate interventions or referrals.

• Log patient interactions within the EHR and CCM management platform.

• Monitor qualifying CCM time to ensure billing compliance.

• Ensure documentation aligns with regulatory, internal quality assurance (QA), and partner requirements.

• Maintain call quality and adherence to established scripts and workflow pathways.

• Achieve or surpass 80% monthly engagement, 90% billable conversion, and high QA/documentation accuracy scores.

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

• Communicate recurring patient needs and trends to the Program Manager.

• Carry out additional duties as assigned that are consistent with the role.

⛳️ Requirements

• Current LPN or Licensed Vocational Nurse (LVN) license.

• Bilingual in Spanish and English.

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

• Strong clinical assessment capabilities, alongside effective communication and documentation skills.

• Comfortable operating in two systems (EHR and CCM platform) concurrently.

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

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

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

• Recommended connections include Cable, Fiber, or DSL, hardwired to the internet device.

• A dedicated workspace free from interruptions to safeguard member PHI/HIPAA information.

• Preferred experience in chronic disease management, virtual care, remote nursing, telehealth programs, CCM regulatory requirements, patient education, and motivational interviewing.

🏝️ Benefits

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

• 12 paid holidays annually.

• Medical, dental, vision, and life insurance, including a Health Savings Account (HSA) with employer match.

• Reimbursement for continuing medical education for eligible roles.

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

• Paid parental leave.

• Comprehensive training and development program beginning with onboarding and continuing throughout your career.

• Eligibility for quarterly bonuses.

• Evergreen provides remote employees with telephony applications and equipment to meet business needs.