Clinical Services Coordinator

THE PERKS

• Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery.
• Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare.
• Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k.
• Fitness reimbursement, commuter benefits, and tuition assistance.
• Great work life benefits- Paid time off, sick time, and 12 paid holidays.
• Fully Remote Schedule

WHAT YOU CAN LOOK FORWARD TO

Patient Outreach, Scheduling & Care Coordination

• Conduct proactive patient outreach to support Annual Wellness Visits, Timely Follow-Up/Transitions of Care, preventive screenings, care management, chronic disease management, and other clinical initiatives.
• Schedule, coordinate, and confirm patient appointments while addressing barriers to care and improving appointment adherence.
• Coordinate services across primary care, specialty care, behavioral health, and community-based organizations.
• Build collaborative relationships with patients, caregivers, providers, and community partners to improve care access and patient outcomes.
• Provide patient education, reinforce care plans, and support self-management activities.
• Assist patients in navigating healthcare services, insurance resources, transportation, and other community supports.

Population Health & Preventive Care

• Utilize EMR, population health registries, Agentic AI tools, and reporting platforms to identify patients due for preventive services, follow-up appointments, and quality interventions.
• Support Annual Wellness Visit workflows, preventive care initiatives, quality measure performance, and value-based care programs.
• Assist with standardized screenings and assessments, including health risk assessment, PHQ-9s and social determinants of health (SDOH) screening, as appropriate.
• Monitor assigned patient work queues and outreach lists to ensure timely completion of clinical and operational priorities.
• Collaborate with Care Transformation Partners to support health centers’ needs and participate in finding solutions to current challenges or barriers.

Timely Follow-Up & Transitions of Care

• Conduct timely outreach following emergency department visits, hospital admissions, and other care transitions to support continuity of care.
• Coordinate post-discharge appointments, medication reconciliation or review, referrals, and additional follow-up activities as directed.
• Identify and escalate clinical, behavioral health, or social concerns to licensed clinicians or appropriate members of the care team.

Clinical Operations & Quality Improvement

• Collaborate with providers and interdisciplinary teams to improve patient engagement, reduce care gaps, and achieve quality and population health goals.
• Participate in quality improvement initiatives, workflow optimization, and implementation of new clinical programs.
• Support standardized workflows and best practices across clinical service lines.
• Assist with onboarding, training, and sharing best practices with team members as needed.
• Contribute to optimizing and documenting workflows to establish standards of care, best practices, and policies.

Documentation, Compliance & Technology

• Maintain accurate, timely, and complete documentation within the EMR and care management platforms.
• Ensure compliance with organizational policies, regulatory requirements, privacy standards, and documentation guidelines.
• Utilize technology-enabled outreach platforms, AI-assisted patient engagement tools, and other digital solutions to enhance workflow efficiency and patient engagement.
• Monitor outreach activities and documentation to support performance reporting and quality metrics

WHAT YOU’LL NEED TO SUCCEED

• 3 years of work experience in care coordination or care/case management, patient outreach, and connecting to community resources
• Bilingual in Spanish and fluent in medical terminology
• Experience in one or more of the following settings:
• Safety-net or public health hospitals
• Federally Qualified Health Centers (FQHCs)
• Academic medical centers
• Ambulatory care
• Physician groups or professional practices
• Community Mental Health Centers
• Substance use treatment settings
• Outpatient mental health services
• Current state licensure as an RN, LPN, LSW, or LCSW a plus. Additional state licensure may be required in any state where the employee provides patient care, including virtual or in-person care.
• Experience in engaging patients with chronic illnesses and needs related to behavioral health and multiple social factors affecting health outcomes.
• Knowledge and experience working with Medicaid and Medicare populations and in value-based care desirable.