Community Care Coordinator (Remote) – Text-Based APCM Program
Skills
- Active LPN or CMA/RMA certification in good standing
- Experience with text-based health platforms and EMRs
- Strong knowledge of community resources, health equity, and social determinants of health
- Excellent written communication and time management skills
- Critical thinking and ability to triage needs with urgency and empathy
Responsibilities
- Conduct post-discharge outreach within 48 hours for Transitional Care Management follow-up
- Identify and coordinate social support services including food, housing, transportation, behavioral health, and financial assistance
- Assist patients with after-care coordination and medication access
- Engage patients via a secure text-based platform and escalate concerns to clinical team members
- Monitor hospital admission and discharge reports and reach out to enrolled patients proactively
- Support patients with navigation of health systems including insurance and provider access
- Participate in daily team huddles and track patient engagement and task completion
- Document activities in EHR/Phamily platform in real-time according to compliance standards
- Escalate critical needs to licensed social workers, nurses, or physicians
- Support quality goals such as reducing readmissions and closing social determinants of health gaps
Education
- Certification as LPN, CMA, or RMA
- Preferred experience in social work, case management, or transitional care coordination
Benefits
- Competitive compensation and benefits package
- Opportunities for professional development and internal promotion
- Flexible remote schedule across CST, EST, or PST time zones
- Supportive multidisciplinary care team environment
Average salary estimate
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