Chronic Care Coordinator

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

📋 Description

• Execute organized outreach, engagement, and follow-up with assigned patient panels.

• Record patient interactions and coordinate subsequent steps utilizing standardized workflows and documentation protocols.

• Manage care transitions, medication reconciliation, and patient assessments for TCM and PIN populations.

• Observe biometric data and symptom patterns for RPM/RTM patients, escalating issues according to established clinical protocols.

• Assist with behavioral health integration (BHI/CHI) through screening, referral coordination, and updating care plans.

• Promote coordination among care teams and route tasks within assigned workflows.

• Ensure documentation is audit-ready and contribute to dashboard inputs for operational monitoring.

• Partner with interdisciplinary teams to promote equity, compliance, and patient-centered outcomes.

• Advocate for a holistic approach to care that addresses patients’ physical, emotional, and social needs.

⛳️ Requirements

• Preferred experience in care coordination, case management, health navigation, or a related patient-support role.

• Familiarity with CMS care models as well as care management documentation and billing requirements is preferred.

• Excellent communication, documentation, organizational, and time management abilities.

• Proficient with digital platforms, dashboards, EMRs, and remote engagement tools.

• A commitment to equitable, patient-centered, and scalable care delivery.

• Active credentials or licensure as an MA, CNA, CMA, LPN/LVN, or RN is preferred.

🏝️ Benefits

• Contract-based position with the possibility of renewal or expansion.

• Remote work opportunity.

• Training provided on internal workflows, escalation protocols, and documentation standards.

• Potential for growth and increased responsibilities as the organization expands.