Job Title: Care Coordinator - Chronic Care Management (CCM) & Remote Patient Monitoring (RPM) - Spanish Location: Remote Employment Type: Full-time Job Summary: We are seeking a dedicated, compassionate, and bilingual Care Coordinator to support the implementation and ongoing management of our Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs, with a specialized focus on patients with rheumatologic conditions . The ideal candidate will have experience in care coordination, preferably in rheumatology, and be fluent in both English and Spanish to effectively engage and support our diverse patient population. Key Responsibilities: Patient Outreach & Enrollment: Conduct telephonic outreach to eligible patients to explain CCM and RPM services, obtain verbal consent, and conduct onboarding. Communicate program benefits and address questions in both English and Spanish. Care Coordination & Case Management: Assist patients in navigating their chronic conditions by creating and updating individualized care plans. Provide monthly non-face-to-face check-ins for enrolled patients as per CMS guidelines. Coordinate referrals, medication adherence, and follow-ups with providers and specialists, particularly for rheumatology patients. Remote Patient Monitoring Support: Educate patients on the use of monitoring devices and ensure successful onboarding to the RPM platform. Monitor incoming data and flag clinically relevant alerts to the appropriate clinical team. Encourage patient compliance with device usage and troubleshoot minor tech issues. Documentation & Reporting: Accurately document all patient interactions, care plans, and time tracking in the electronic health record (EHR) and/or care management platform. Maintain compliance with CMS and organizational policies regarding care management documentation and billing. Collaboration & Communication: Collaborate with physicians, nurses, and other clinical staff to ensure continuity and quality of care. Act as the primary liaison between patients, caregivers, providers, and community resources to ensure seamless care. Attend regular team meetings and provide feedback on patient progress and program improvement opportunities. Qualifications required: Background in nursing or medical assisting (MA/CNA) , social work , or public health . Previous experience with CCM and/or RPM programs . Fluency in English and Spanish (verbal and written). Strong communication, interpersonal, and organizational skills. Comfortable working with EHR systems and digital health platforms. Preferred: Experience working in nephrology, internal medicine, or primary care settings . Familiarity with chronic conditions commonly managed in rheumatology , such as rheumatoid arthritis, lupus, and fibromyalgia. Knowledge of CMS billing requirements for chronic care management and remote monitoring. Compensation & Benefits: Competitive hourly rate or salary (based on experience and credentials) Flexible work schedule and potential for remote work Training and certification support for CMS-compliant CCM/RPM services Opportunity to work with an innovative care model that enhances patient outcomes
