Chronic Care Coordinator

Position Summary
We are seeking a detail-oriented and compassionate Personal Care Coordinator to support patients across multiple care management programs, including CCM, PCM, RPM, RTM, APCM, TCM, BHI, CHI, and PIN. This role supports clinical and operational workflows, ensuring patients receive timely, personalized, and compliant support across care transitions, chronic condition management, behavioral health, and preventive care pathways.

We are a fast-growing organization building scalable, patient-centered care management operations. This is an opportunity for a self-starter who wants to do meaningful work in a remote environment and grow with the company over time. For the right person, this role can develop into a broader and more impactful position as our programs, team, and clinical operations continue to expand.

We believe care should be compassionate, accountable, and patient-centered. This role is part of a broader mission to deliver high-quality, equitable care that improves patient outcomes and access. Personal Care Coordinators are expected to reflect these values in every patient interaction, team collaboration, and operational decision.

Key Responsibilities

• Conduct structured outreach, engagement, and follow-up across assigned patient panels
• Document patient interactions and coordinate next steps using standardized workflows and documentation protocols
• Coordinate care transitions, medication reconciliation, and patient needs assessments for TCM and PIN populations
• Monitor biometric data and symptom trends for RPM/RTM patients, escalating concerns in accordance with established clinical protocols
• Support behavioral health integration (BHI/CHI) through screening, referral coordination, and care plan updates
• Facilitate care team coordination and task routing across assigned workflows
• Maintain audit-ready documentation and contribute to dashboard inputs for operational tracking
• Collaborate with interdisciplinary teams to ensure equity, compliance, and patient-centered outcomes
• Support a whole-person approach to care that recognizes patients’ physical, emotional, and social needs

Requirements

Qualifications

• Experience in care coordination, case management, health navigation, or a similar patient-support role preferred
• Familiarity with CMS care models and care management documentation and billing requirements preferred
• Strong communication, documentation, organization, and time management skills
• Comfort with digital platforms, dashboards, EMRs, and remote engagement tools
• Commitment to equitable, patient-centered, and scalable care delivery
• Active credential or licensure as an MA, CNA, CMA, LPN/LVN, or RN preferred

Benefits

Contract Details

• Contract-based position with potential for renewal or expansion
• Remote position
• Training provided on internal workflows, escalation protocols, and documentation standards
• Opportunity for growth and expanded responsibility as the organization continues to scale