Community Care Coordinator (Remote) – Text-Based APCM Program

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

Department: Clinical Operations

Location: Remote (Candidates must be willing to work within CST, PST or EST time zone)

Reports To: Associate Director of Clinical Services

Position Type: Full-Time

About The Role

We are seeking a compassionate and resourceful Community Care Coordinator to join our virtual care team. This role is ideal for a Licensed Medical Assistant (MA) or Licensed Practical Nurse (LPN) with strong communication skills and a heart for community impact. In this role, you’ll support patients transitioning from hospital to home, assist with identifying community resources, and help reduce gaps in care through thoughtful, timely, and tech-enabled outreach.

As a vital member of our Advanced Primary Care Management (APCM) team, you will provide post-discharge follow-up (TCM), coordinate community support services, and address non-clinical barriers to care for patients with chronic conditions. You will work under the direction of the Associate Director of Clinical Operations and collaborate closely with care managers, RNs, social workers, and providers to ensure continuity of care and successful patient outcomes.

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

• Conduct post-discharge outreach within 48 hours of hospital or ED discharge for TCM (Transitional Care Management) follow-up.
• Identify and help coordinate social support services: food, housing, transportation, behavioral health, and financial assistance.
• Assist patients with after-care coordination, such as scheduling follow-up appointments and addressing medication access issues.
• Use a secure text-based platform to engage patients, respond to needs, and escalate care concerns to the appropriate clinical team member.
• Monitor hospital admission and discharge reports and proactively reach out to enrolled patients.
• Support patients with navigation of health systems, including insurance questions and provider access.
• Participate in daily team huddles, report progress, and track patient engagement and task completion.
• Document all activities in EHR/Phamily platform in real-time according to compliance standards.
• Escalate critical needs to licensed social workers, nurses, or physicians based on escalation guidelines.
• Support quality goals such as reducing readmissions, improving care coordination, and closing SDOH gaps.
  
  

Key Skills & Qualifications

• Required: Active LPN or CMA/RMA certification in good standing
• Preferred: Experience in social work, case management, hospital navigation, or transitional care coordination
• 2+ years of experience in clinical, community health, or post-acute care settings
• Comfortable using text-based health platforms, EMRs, and digital communication tools
• Strong knowledge of community resources, health equity, and SDOH
• Critical thinking skills and ability to triage needs with urgency and empathy
• Excellent written communication and time management
• Bilingual (Spanish/English) a plus but not required
  
  

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?

• Be a part of a 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
• Professional development support
• Be part of redefining how care is delivered—one text at a time