Care Coordinator, LPN

Evergreen Nephrology

. Conduct monthly clinical check-ins and CCM touchpoints for assigned patient panels .

Posted 10/8/2026full-timeRemote • California • United StatesJunior💰 $55,000 - $65,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment, care coordination, and patient education within the scope of LPN practice, while effectively managing workflows in EHR and CCM platforms. Proficient in addressing chronic disease management and ensuring compliance with regulatory standards.

Highest-signal resume keywords

Active California LPN LicenseClinical Assessment SkillsEHR and CCM Platform ProficiencyChronic Disease Management ExperienceBilingual Spanish/English

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentMedication Adherence EvaluationSymptom Management EducationDocumentation in EHRPatient Chart ReviewStructured Workflow ManagementQuality Assurance AuditsMetric-Driven WorkflowPatient Interaction TrackingTriage Pathway Navigation

Soft Skills

Communication SkillsRelationship BuildingMotivational InterviewingTeam CollaborationPatient Education

Tools & Technologies

EHR SystemsCCM PlatformsMS Office SuiteOutlookTeams

Certifications & Qualifications

California LPN LicenseLicensed Vocational Nurse (LVN)

Industry Keywords

Chronic Kidney Disease (CKD)Care CoordinationPopulation HealthTelehealth ProgramsHIPAA Compliance

About the role

Key responsibilities & impact

Conduct monthly clinical check-ins and CCM touchpoints for assigned patient panels
Build ongoing relationships with patients and caregivers through regular outreach using SMS and phone when appropriate
Review patient charts, diagnoses, kidney disease history, medications, labs, imaging, and treatment cycles before calls
Explain CCM participation and reinforce program benefits
Conduct structured symptom assessments and evaluate changes using licensed clinical judgment
Assess medication adherence issues, side effects, and regimen confusion
Identify clinical red flags and escalate urgent issues through defined triage pathways
Collaborate with providers and care teams on symptom changes, concerns, and medication issues
Route EHR messages with clinically relevant documentation
Coordinate follow-up appointments, labs, nephrology appointments, and missed-care reduction
Reinforce CKD and chronic disease care plans and provide symptom-management education within LPN scope
Support medication, lifestyle, and follow-up adherence
Identify social, behavioral, or access barriers and arrange interventions or referrals
Document patient interactions in the EHR and CCM platform
Track qualifying CCM time for billing compliance and meet regulatory, QA, and partner documentation standards
Maintain call quality and follow scripting and workflow pathways
Maintain or exceed 80% monthly engagement and 90% billable conversion
Participate in peer reviews, QA audits, coaching, and continuous education
Communicate recurring patient needs and trends to the Program Manager
Perform other duties consistent with the role as assigned

Requirements

What you’ll need

Active California LPN or Licensed Vocational Nurse (LVN) license
Minimum 1–2 years of clinical experience in ambulatory care, population health, care coordination, or case management
Strong clinical assessment, communication, and documentation skills
Comfortable working in two systems simultaneously: EHR and CCM platform
Ability to manage a structured, metric-driven workflow with reliability
Intermediate skills with MS Office Suite, including Outlook and Teams
Ability to work effectively in a primarily remote environment
Home internet supporting at least 25 Mbps download and 10 Mbps upload; cable, fiber, or DSL hardwired connections recommended
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
Preferred: experience in chronic disease management
Preferred: bilingual Spanish/English
Preferred: prior work in virtual care, remote nursing, or telehealth programs
Preferred: familiarity with CCM regulatory requirements
Preferred: strong patient education and motivational interviewing skills

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
401(k) program with Evergreen matching up to 4% of contributions after six months of tenure
Paid parental leave
Robust training and development program from onboarding throughout your career
Quarterly bonus
Remote employees provided telephony applications and equipment to meet business requirements