Title: Remote Care Coordinator

Position Summary

The Remote Care Coordinator (RCC) delivers longitudinal Care Management services through proactive patient engagement, ongoing chart and care plan review, care coordination, documentation, and collaboration with patients, caregivers, providers, and interdisciplinary team members.

Depending on operational assignment, the RCC serves either as the primary Care Manager responsible for an assigned panel of in-office patients or as a Care Management partner supporting patients within Assisted Living Facility (ALF) settings.

Regardless of assignment, the RCC is responsible for providing consistent, high-quality Care Management services, maintaining timely and accurate documentation, identifying patient needs and barriers, coordinating appropriate follow-up, and meeting established Care Management productivity and performance expectations.

1. In-Office Care Management

• Serve as the primary Care Manager for an assigned panel of patients enrolled in Care Management.
• Identify and enroll eligible patients into appropriate Care Management programs.
• Obtain and document required patient consent.
• Complete comprehensive patient assessments and establish initial Care Management needs.
• Develop, maintain, and update individualized care plans.
• Perform routine chart and care plan reviews to identify changes in patient status, care gaps, barriers, and opportunities for Care Management intervention.
• Conduct proactive patient outreach and ongoing monthly Care Management activities based on individual patient needs.
• Monitor patient progress and identify changes or concerns requiring additional intervention.
• Coordinate care and communicate relevant patient updates with providers and interdisciplinary team members.
• Escalate clinical concerns or other patient needs to the appropriate member of the care team.

2. Assisted Living Facility (ALF) Care Management Support

• Partner with the assigned Care Coordinator to support longitudinal management of an assigned patient population.
• Conduct routine outreach to patients, family members, caregivers, and Powers of Attorney (POAs), as appropriate.
• Perform Care Management activities and follow-up based on identified patient needs.
• Support care coordination across providers, facilities, caregivers, and other members of the patient's healthcare team.
• Communicate significant patient updates, barriers, and concerns to the assigned Care Coordinator.
• Contribute to continuity of care through consistent, collaborative patient management.

3. Documentation & Compliance

• Document all Care Management services accurately and in a timely manner.
• Maintain complete patient documentation in accordance with organizational Care Management Standards.
• Accurately document qualifying Care Management time and activities.
• Maintain care plans and other required Care Management documentation throughout the patient's enrollment.
• Comply with applicable payer requirements, organizational policies, and established Care Management workflows.
• Maintain HIPAA compliance and protect patient confidentiality at all times.

4. Patient Engagement & Care Coordination

• Develop effective working relationships with patients, caregivers, providers, facility staff, and interdisciplinary team members.
• Support patients in understanding and following established care plans and addressing barriers to care.
• Identify social, financial, access, or other barriers that may affect the patient's ability to follow their care plan.
• Connect patients with appropriate internal or community resources when needs are identified.
• Coordinate services and communication across the patient's healthcare team.
• Identify opportunities to improve continuity of care and patient outcomes through proactive engagement and follow-up.
• Encourage appropriate patient participation and engagement in ongoing Care Management services.

5. Professional Excellence

• Demonstrate professionalism, reliability, and accountability in all interactions.
• Communicate clearly and effectively with patients, caregivers, providers, and team members.
• Maintain strong organizational and time-management skills while independently managing assigned responsibilities.
• Demonstrate the ability to prioritize patient needs and manage a longitudinal patient population.
• Adapt to changing patient needs and operational priorities.
• Participate in team meetings, training, and Care Management improvement initiatives.
• Consistently meet established organizational and Care Management performance expectations.

Key Performance Indicators

Performance may be evaluated using measures including:

• Patient enrollment and ongoing engagement
• Effective management of assigned patient panel or population
• Care plan completion, maintenance, and quality
• Completion of required monthly Care Management activities
• Documentation accuracy and timeliness
• Accurate documentation of qualifying Care Management time
• Productivity and utilization expectations
• Patient outreach and follow-up
• Care coordination effectiveness
• Compliance with organizational Care Management Standards and applicable requirements

Preferred Qualifications

• Medical Assistant (MA), Licensed Practical Nurse (LPN), or similar clinical healthcare background strongly preferred.
• Previous experience in Care Management, Chronic Care Management (CCM), Advanced Primary Care Management (APCM), population health, or a similar longitudinal patient-support program.
• Experience working within a primary care or ambulatory healthcare environment.
• Experience with Athenahealth, ThoroughCare, or similar EHR and Care Management platforms.
• Familiarity with Care Management documentation, time tracking, and payer requirements.
• Bilingual skills are a plus.

Work Environment

This is a fully remote position requiring consistent availability during established business hours and reliable internet access. The RCC works independently while maintaining frequent communication and collaboration with the broader Care Management and clinical teams.

The position requires regular use of electronic health records, Care Management platforms, telephone communication, secure digital communication, and other technology necessary to support an assigned patient population.

• Previous experience in healthcare, care coordination, patient support, population health, or a related healthcare setting.
• Strong verbal and written communication skills with the ability to effectively engage patients, caregivers, and healthcare team members.
• Strong organizational and time-management skills with the ability to independently manage a patient population and multiple ongoing priorities.
• Ability to accurately and consistently document patient interactions and Care Management activities.
• Comfortable working within electronic health records, Care Management platforms, and other healthcare technology systems.
• Ability to recognize concerns requiring clinical or operational escalation and communicate them to the appropriate team member.
• Ability to work effectively and independently in a remote environment.