Clinical Care Coordinator

Job Title: Clinical Care Coordinator (Remote) – Text-Based APCM Program

 Department: Clinical Operations
Location: Remote (designated roles available in CST, EST, or PST)
Reports To: Clinical Programs Manager / Associate Director of Clinical Services
Position Type: Full-Time

About the Role

We are seeking a compassionate, organized, and tech-savvy Clinical Care Coordinator to support patients with chronic conditions in our text-based Advanced Primary Care Management (APCM) program. This remote role focuses on delivering proactive, high-quality care through digital communication tools, driving better health outcomes for Medicare and older adult populations.

This position is ideal for healthcare professionals who thrive in a virtual care setting, value patient engagement, and are skilled in critical thinking and care coordination.

Prioritizing hires in New Mexico, Illinois and Washington in initial launch. Candidates in other locations may apply, but applications will be held until there are additional resources needed outside of the initial target areas. 

 Key Responsibilities

• Serve as the first line of communication for patients via a secure, text-based platform
• Monitor and respond to patient messages and check-ins in a timely, compassionate, and professional manner
• Identify, assess, and triage clinical concerns, SDOH needs, and care coordination barriers
• Collaborate with RNs, NPs, and Social Workers to ensure timely escalation and follow-through
• Develop and update personalized care plans for patients with chronic conditions (e.g., hypertension, diabetes, COPD)
• Track engagement, log care time, and document all communication per HIPAA and program guidelines
• Support monthly billing processes by ensuring all time and care plans are accurately recorded
• Participate in daily huddles, team meetings, and ongoing training to improve patient outcomes and workflows
• Provide warm, empathetic communication while navigating diverse patient populations and needs
  
  

Key Skills & Qualifications

• CMA, CCMA, RMA, or LPN/LVN license required
• 2+ years of experience in a clinical or care coordination role (primary care, chronic care management, home health, etc.)
• Strong critical thinking and problem-solving skills in a fast-paced environment
• Ability to independently manage a digital patient panel and prioritize escalations effectively
• Excellent written communication and documentation skills
• Comfort using EMRs, care coordination platforms, and digital messaging tools
• Knowledge of Medicare CCM/APCM programs a plus
• Bilingual (Spanish) is a bonus but not required
• Must be located within the continental United States and have access to reliable internet and ability to work in a specified time zone - either CST, EST, or PST depending on client and candidate location
• Access to Internet 5G

Schedule & Work Environment

• Full-time, Monday - Friday
• Flexible remote schedule across CST, EST, or PST time zones
  
• 1-hour lunch break, daily huddles with manager/team
• Ongoing support from a multidisciplinary care team

Why Join Us?

• Mission-driven organization focused on health equity and innovative digital care
• Collaborative, diverse, and growth-focused culture
• Opportunities for professional development and internal promotion
• Competitive compensation and benefits package
• Be part of redefining how care is delivered—one text at a time