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Salary: USD 45,000 - 52,000 / annual
Evergreen Nephrology is seeking a bilingual Care Coordinator to support proactive care coordination services for patients with complex chronic conditions, including chronic kidney disease (CKD), hypertension, diabetes, and cardiovascular disease. This fully remote role is operationally focused and outreach-driven, requiring strong organizational skills and patient communication abilities.
You will work under clinical supervision to conduct patient outreach, create and maintain care plans, support documentation compliance, and coordinate communication between patients, providers, and healthcare partners. The role manages a high-volume patient panel using SMS as the primary engagement channel, with phone outreach as needed.
Key responsibilities include:
- Supporting CCM patient enrollment and onboarding; verifying eligibility based on program guidelines
- Conducting weekly text and telephonic outreach to enrolled patients to achieve Medicare CCM billing engagement time standards
- Documenting patient interactions accurately in CCM platforms and EHR systems while maintaining HIPAA compliance
- Identifying barriers to adherence (medication access, transportation, social needs) and escalating concerns to clinical staff
- Facilitating patient access to providers, supporting care transitions post-hospitalization, and coordinating referrals
- Managing patient messaging workflows and collaborating with remote clinical and operational teams
The position requires working 8:00am–5:00pm Pacific Time. Evergreen will provide telephony applications and equipment; you must have a dedicated, quiet workspace and internet with minimum 25 Mbps download and 10 Mbps upload speeds (hardwired connection recommended).
Required Qualifications:
- Certified Medical Assistant (CMA)
- Bilingual fluency in Spanish and English
- 1–3 years of healthcare experience
- Strong clinical assessment, communication, and documentation skills
- Comfortable working simultaneously in two systems (EHR + CCM platform)
- Ability to manage structured, metric-driven workflows with reliability
- Intermediate proficiency with MS Office Suite (Outlook, Teams)
- Ability to work effectively in a remote environment with dedicated workspace and HIPAA-compliant setup
Preferred Qualifications:
- Experience with chronic kidney disease or nephrology patient populations
- Dialysis patient coordination experience
- Medication adherence monitoring background
- Experience in chronic disease management or virtual care/telehealth programs
- Familiarity with CCM regulatory requirements
- Strong patient education and motivational interviewing skills
