Conduct monthly Chronic Care Management (CCM) outreach calls and enroll patients
Perform health risk assessments and support Transitional Care Management (TCM)
Assist with Remote Patient Monitoring (RPM) and chronic condition tracking
Educate patients and families on diagnoses, medications, and care plans
Coordinate care between patients, providers, and internal teams
Encourage adherence to treatment plans and patient self-management
Accurately document all interactions in EHR systems
Maintain productivity targets while delivering empathetic patient care
Ensure compliance with HIPAA, CMS, and company standards

Active, unencumbered LPN/LVN license
Must live in MST or PST (required)
Fluent in English and Spanish
Active BLS certification
Strong proficiency with EHR systems
Proficiency in Google Suite
Ability to work independently in a HIPAA-compliant home office
Strong clinical reasoning, problem-solving, and communication skills
Excellent verbal and written communication abilities
Experience in care coordination, CCM, TCM, or remote patient monitoring (Nice to Have)
Familiarity with community resource navigation (Nice to Have)
Experience educating patients/families on chronic conditions (Nice to Have)
Knowledge of CMS compliance, reporting, or quality measures (Nice to Have)
Team-oriented mindset in a remote environment (Nice to Have)
Private, distraction-free, HIPAA-compliant workspace requirement
Reliable high-speed internet requirement
Dual monitor setup requirement

LPN Care Coordinator – Bilingual, MST/PST Only

Key skills