Clinical Services Coordinator

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

📋 Description

• Perform proactive outreach to patients for Annual Wellness Visits, Timely Follow-Up/Transitions of Care, preventive screenings, care management, chronic disease management, and other clinical initiatives.

• Organize, schedule, and confirm patient appointments; tackle barriers to care and enhance appointment adherence.

• Coordinate services among primary care, specialty care, behavioral health, and community organizations.

• Develop relationships with patients, caregivers, providers, and community partners.

• Deliver patient education, reinforce care plans, and encourage self-management.

• Assist patients in navigating healthcare services, insurance resources, transportation, and community support.

• Utilize EMR, population health registries, Agentic AI tools, and reporting platforms to identify outreach and quality-improvement opportunities.

• Support workflows for Annual Wellness Visits, preventive care initiatives, quality measures, and value-based care programs.

• Aid in health risk assessments, PHQ-9s, and screenings for social determinants of health.

• Monitor patient work queues and outreach lists.

• Conduct outreach following emergency department visits, hospital admissions, and other care transitions.

• Organize post-discharge appointments, medication reconciliation or review, referrals, and follow-up.

• Elevate clinical, behavioral health, or social concerns to licensed clinicians or relevant care-team members.

• Collaborate with providers and interdisciplinary teams to enhance patient engagement, minimize care gaps, and meet quality objectives.

• Engage in quality improvement, workflow optimization, implementing new clinical programs, onboarding, training, and sharing best practices.

• Keep precise EMR and care-management documentation, ensuring compliance with policies, regulations, privacy standards, and documentation guidelines.

• Leverage AI-assisted patient engagement tools and digital solutions to enhance workflow efficiency and patient interaction.

• Monitor outreach documentation for performance reporting and quality metrics.

⛳️ Requirements

• A minimum of 3 years of experience in care coordination or care/case management, patient outreach, and connecting to community resources.

• Bilingual in Spanish and proficient in medical terminology.

• Experience in safety-net or public health hospitals, Federally Qualified Health Centers (FQHCs), academic medical centers, ambulatory care, physician groups or professional practices, community mental health centers, substance use treatment settings, or outpatient mental health services.

• Current state licensure as an RN, LPN, LSW, or LCSW is a plus; additional state licensure may be required in any state where the employee provides patient care, including virtual or in-person care.

• Experience engaging patients with chronic illnesses and needs related to behavioral health and multiple social factors affecting health outcomes.

• Knowledge and experience working with Medicaid and Medicare populations and familiarity with value-based care is desirable.

🏝️ Benefits

• Enjoy a fun, challenging, and collaborative work environment with passionate colleagues who care deeply about healthcare delivery.

• Recognized as one of the Best Places to Work in Healthcare by Modern Healthcare.

• Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k.

• Fitness reimbursement, commuter benefits, and tuition assistance.

• Paid time off, sick time, and 12 paid holidays.

• Fully Remote Schedule.