Care Coordinator, Bilingual

Evergreen Nephrology

. Support proactive care coordination services for patients with complex chronic conditions, including CKD, hypertension, diabetes, cardiovascular disease, and related comorbidities .

Posted 10/8/2026full-timeRemote • United StatesJunior💰 $45,000 - $52,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in chronic disease management, patient engagement, and care coordination, with a strong focus on compliance with HIPAA and PHI regulations. Proficient in utilizing EHR and CCM platforms to enhance patient care and streamline workflows.

Highest-signal resume keywords

Certified Medical AssistantChronic Disease ManagementEHR Platform ProficiencyBilingual (Spanish/English)Strong Clinical Assessment Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Patient EngagementCare CoordinationDocumentation SkillsClinical AssessmentMetric-Driven Workflow ManagementMedication Access IdentificationPatient EducationMotivational InterviewingCCM Regulatory FamiliarityTelehealth Experience

Soft Skills

Communication SkillsReliabilityCollaborationAdaptabilityInterpersonal Skills

Tools & Technologies

CCM PlatformEHR SystemsMS Office SuiteOutlookTeams

Certifications & Qualifications

Certified Medical Assistant

Industry Keywords

Chronic ConditionsCKDHypertensionDiabetesCardiovascular DiseasePatient ConsentHIPAA CompliancePatient Messaging WorkflowsRemote NursingVirtual Care

About the role

Key responsibilities & impact

Support proactive care coordination services for patients with complex chronic conditions, including CKD, hypertension, diabetes, cardiovascular disease, and related comorbidities
Support CCM patient enrollment and onboarding activities
Verify eligibility based on Evergreen and payer program guidelines
Ensure patient consent documentation is completed prior to outreach
Maintain patient engagement and identify inactive or non-engaged patients for escalation
Conduct weekly text and telephone outreach to enrolled CCM patients
Achieve engagement time standards aligned with Medicare CCM billing requirements
Reinforce provider-directed care plans during patient interactions
Identify barriers to adherence, including medication access, transportation, or social needs
Document patient interactions in the CCM patient management platform and EHR systems
Track engagement time and maintain audit-ready documentation
Ensure HIPAA and PHI compliance
Facilitate patient access to referring providers and clinical staff
Support care transitions after hospitalizations or ED visits
Coordinate referrals and follow-up appointments
Escalate symptom concerns or medication issues to licensed clinical staff
Utilize CCM and EHR platforms daily
Manage patient messaging workflows
Collaborate with remote clinical and operational teams

Requirements

What you’ll need

Certified Medical Assistant
Bilingual (Spanish/English)
1–3 years healthcare experience
Chronic disease or nephrology experience is preferred
Strong clinical assessment, communication, and documentation skills
Comfortable working in two systems (EHR + CCM platform) simultaneously
Ability to manage a structured, metric-driven workflow with reliability
Intermediate skills with MS Office Suite of products including Outlook and Teams
Able to work effectively in a primarily remote environment
Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps
Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Experience in chronic disease management is preferred
Prior work in virtual care, remote nursing, or telehealth programs is preferred
Familiarity with CCM regulatory requirements is preferred
Strong patient education and motivational interviewing skills are preferred

Benefits

Comp & perks

Paid time off starting at 4 weeks for full-time employees
12 paid holidays per year
Medical, dental, vision and life insurance, including an HSA with employer match
Reimbursement for continuing medical education for eligible roles
A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
Paid parental leave
A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Bonus eligibility
Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role