Care Coordinator *MUST SPEAK SPANISH OR MANDARIN*Pay: $20.00 - $22.50/hr + quarterly bonuses of up to $500Location: Remote (in NYC/ NJ area)Reports to: Clinical Director / Supervising NurseAbout Us:We partners exclusively with Federally Qualified Health Centers (FQHCs) to deliver outsourced care management services that blend technology with human connection. Our remote teams support chronic care management (CCM), remote patient monitoring (RPM), behavioral health integration (BHI), and advanced primary care management (APCM) programs—all designed for FQHC workflows, billing, and patient needs.We exist to reduce the burden on health center staff, expand access between visits, and improve outcomes—especially for underserved communities.Position SummaryWe are hiring a Care Coordinator to support patients enrolled in chronic care programs by assisting patients with multiple chronic conditions in navigating their care. The care coordinator works closely with care managers, nurses, primary care providers and other members of the interdisciplinary team to promote patient engagement, ensure timely follow-up and connect patients to needed medical and community resources. This role focuses on patient outreach, care plan support and coordination of services to improve health outcomes and reduce avoidable hospitalizations. This is a high-touch, relationship-driven role ideal for those passionate about engaging underserved patients in high quality care, coordinating care remotely, and improving health outcomes—one call at a time!Key Responsibilities Patient Engagement & SupportPerform patient intake, explain program benefits and answer questions, and enroll them into the appropriate care management services.Conduct frequent patient check-ins to gather health updates, reinforce care plans, address any outstanding needs and support patient understanding.Build rapport and trust, using clear and simple language across diverse and often underserved populations.Screen for outstanding health maintenance screenings, including social determinants of health (SDOH) and coordinate follow-up as needed. Care Coordination & Team CollaborationWork closely with care managers, nurses, and providers to ensure seamless patient care.Participate in team huddles, case conferences, and quality improvement initiatives.Escalate clinical or psychosocial concerns to licensed care managers or providers for follow-up.Support clinical staff in tracking patient progress, scheduling follow-ups, and managing communications.Facilitate communication between patients, providers, pharmacies, and community resources.Assist with referrals to specialists, social services, behavioral health, and community-based support programs.Track patient follow-up after hospitalizations, emergency department visits, and care transitions.Coordinate transportation, interpreter services, and other non-clinical needs to reduce barriers to care.Monitor and escalate patient concerns or abnormal readings (e.g., RPM data) to the nurse or clinical team.Support language access by coordinating translation services when needed.Documentation & ComplianceDocument patient interactions, outreach efforts, and care coordination activities in the electronic health record (EHR).Maintain accurate logs of patient enrollment and program activities.Support compliance with program requirements, including CMS Chronic Care Management and population health quality measures.Operational TasksManage outreach lists and task queues for assigned patients.Follow scripted workflows for enrollment and re-engagement.Other duties as assignedQualifications Required2-3 years of experience working in a clinical, community health, or primary care setting.Bilingual in Spanish or MandarinPassion for working with diverse, underserved populations.Excellent communication and active listening skills; ability to engage patients from diverse backgrounds.Strong organizational, time management, phone and communication skills, with a patient-centered mindset.Comfortable using technology (EHRs, patient engagement platforms, video visits, etc.). Comfort with patient outreach by phone, in-person, and virtually.PreferredFamiliarity with community resources, healthcare systems, or care coordination strongly desired. Prior experience in care management, chronic care coordination, or remote monitoring.Familiarity with Medicare/Medicaid patients and programs such as CCM, RPM, or TCM.What We OfferFull benefits & overtime eligabilityFully remote role with flexible hoursTraining and support from experienced care management leadersMission-driven work serving high-need communitiesOpportunities for growth into more advanced care roles
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