Care Coordinator

This is a remote position.

Job Description

The Care Coordinator is a clinical cornerstone of Vitasora Health’s remote care team, responsible for managing the ongoing health needs of patients enrolled in Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. This role combines clinical expertise with advanced patient engagement skill, including motivational interviewing and health coaching, to build meaningful and trusting relationships that support lasting behavior change and improved outcomes for patients managing chronic conditions such as cardiovascular disease, diabetes, obesity, and respiratory challenges. Care Coordinators receive warm hand-offs of newly enrolled patients and are responsible for delivering a seamless, white glove onboarding experience that sets the tone for the ongoing care relationship. Guided by our values of Empathy First, Relentless Advocacy, Radical Simplicity, and Shared Growth, the Care Coordinator delivers care that goes beyond the clinic.

Core Responsibilities

Patient Engagement and Health Coaching

• Conduct monthly outreach calls with assigned patients using motivational interviewing techniques including open-ended questions, reflective listening, affirmation, and summarizing to foster intrinsic motivation and support self-directed health goals.
  
• Apply health coaching principles to guide patients through goal-setting, behavior change planning, and accountability, meeting each patient where they are in their readiness to change.
  
• Develop and regularly update individualized CCM care plans based on comprehensive patient assessments, personal values, and stated health priorities.
  
• Provide tailored health education and self-management strategies for chronic conditions using plain language and culturally responsive communication.
  
• Address social determinants of health, including economic, environmental, and social barriers that impact patient engagement and care access, particularly in rural and underserved communities.
  

Patient Onboarding

• Receive warm hand-offs of newly enrolled patients from the enrollment team and deliver a seamless, white glove onboarding experience that establishes trust and sets the foundation for the ongoing care relationship.
  
• Complete baseline assessments covering health history, medications, social determinants, and patient goals to inform initial care plan development.
  
• Use motivational interviewing during onboarding conversations to build rapport, assess readiness, and establish early engagement.
  
• Partner with billing, clinical leadership, and referring providers to ensure accurate onboarding and seamless EHR setup.
  

Care Coordination and Interdisciplinary Collaboration

• Serve as the connective thread between patients and their broader care teams, facilitating warm hand-offs and timely communication with physicians, nurses, social workers, and specialists.
  
• Monitor patient progress through remote monitoring data and regular touchpoints and escalate clinical concerns to appropriate providers using structured communication protocols.
  
• Collaborate with interdisciplinary teams to co-develop care strategies, align on shared goals, and optimize patient outcomes across the care continuum.
  
• Participate in team huddles and case reviews to stay aligned on program priorities and share insights from patient interactions.
  

Clinical Documentation and Compliance

• Maintain accurate, timely, and HIPAA-compliant documentation of all patient interactions, care plans, and clinical observations in the Electronic Health Record system.
  
• Ensure adherence to CMS guidelines for Chronic Care Management services, NCQA standards, Joint Commission requirements, and applicable regulations.
  
• Track patient engagement metrics, document motivational interviewing and health coaching outcomes, and contribute to reporting on program performance and patient progress.
  
• Identify patterns in patient barriers and recommend workflow or care plan improvements to the clinical leadership team.
  

Patient Advocacy and Support

• Identify and proactively address barriers to care access, connecting patients with community resources, healthcare services, and support networks.
  
• Promote culturally competent, patient-centered care that honors the unique values, preferences, and lived experiences of individual served.
  
• Champion the patient’s voice within the care team, ensuring their goals and concerns are heard, respected, and incorporated into clinical decision-making.
  

This role may require completion of tasks and responsibilities outside of those listed above as business needs evolve. Flexibility and a willingness to contribute beyond defined expectations is an important part of this role.

Requirements

Required Qualifications

• All certifications and licenses must be current and in good standing and will be verified through primary source before hire.
  

• Demonstrated knowledge of and experience applying motivational interviewing and health coaching techniques in a clinical or patient engagement setting.
  
• Proficiency in EHR systems, telehealth platforms, and remote patient monitoring tools.
  
• Strong verbal and written communication skills with the ability to engage patients with empathy, navigate objections, and promote behavior change.
  
• Familiarity with CMS CCM guidelines, HIPAA regulations, NCQA standards, and applicable compliance requirements.
  

• Bilingual proficiency in English and Spanish. Additional languages welcome.
  
• Experience working with Medicare and Medicaid patients and managing complex chronic disease populations.
  
• Knowledge of social determinants of health and their impact on rural and underserved communities.
  
• Prior experience in telehealth, RPM, or other virtual care delivery models.
  
• Proven ability to build rapport quickly and handle sensitive conversations with empathy and professionalism.
  
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Benefits

Our Mission: Giving doctors a complete view with care that’s always on. Vitasora expands the capacity of healthcare practitioners to give exceptional care by providing insights beyond the limitations of the clinic, no matter where patients are.

Our Vision: A world where care never stops. A world where living with a chronic condition no longer means navigating it alone — where every patient has a care-keeper by their side and every clinician is empowered to extend their reach beyond the exam room.

Vitasora Health USA Inc is an Equal Opportunity Employer (EOE) and does not discriminate based on race, color, religion, gender, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law, including but not limited to gender identity, gender expression, marital status, medical condition, genetic information, ancestry, and age. We are committed to fostering an inclusive and diverse workplace that reflects the communities we serve.