Care Concierge

About the role

This is an opportunity to join a growing care navigation program at a moment when your contribution will directly shape how it scales. As a Care Concierge, you are the steady presence in a patient's healthcare journey — the person who keeps all the moving pieces connected, translates what matters, and makes sure nothing falls through the cracks. You will support older adults managing serious, high-risk chronic conditions — heart failure, COPD, diabetes, dementia, cancer — through proactive care coordination, education, and advocacy. This is remote work with deep human connection: you will build trust with patients over time, help them navigate a complex healthcare system, address barriers to care, and partner with clinical teams to support better health outcomes.

What You'll Do

• Serve as the primary point of contact for enrolled patients, building trust and rapport over time through consistent, compassionate outreach
• Conduct regular check-ins with patients to assess their health status, care needs, and social barriers — meeting them where they are emotionally and practically
• Maintain a caseload of approximately 150 patients, prioritizing outreach based on clinical acuity, recent transitions, and care gaps
• Build relationships with patients' family members and caregivers when appropriate to support coordinated care
• Conduct the initial welcome visit ahead of the initiating MD visit — introduce the program, explain its value, and in some cases secure patient consent to enroll. Comfortable guiding hesitant patients toward a "yes" through a trust-based, persuasive conversation.
• Navigate patients through the healthcare system — coordinating appointments, facilitating communication between providers, and ensuring care plans are understood and actionable
• Support medication adherence by identifying barriers, educating on proper use, and escalating discrepancies or concerns to clinical staff
• Help patients access durable medical equipment, transportation services, meal programs, and other community-based resources that support their health and independence
• Escalate clinical concerns — new symptoms, worsening conditions, or urgent needs — to the supervising LVN or clinical team promptly and clearly
• Provide condition-specific education tailored to the patient's literacy level, language, and learning preferences — reinforcing what their clinical team has taught them
• Coach patients on self-management strategies: symptom monitoring, when to call the doctor, medication routines, diet modifications, and activity goals
• Use motivational interviewing techniques to support behavior change and goal-setting in partnership with the patient
• Deliver culturally sensitive, trauma-informed care that respects patients' beliefs, preferences, and lived experiences
• Post-Hospital & Emergency Department Follow-Up
• Conduct timely follow-up calls within 24-72 hours of hospital discharge or ED visit to support safe transitions home
• Review discharge instructions with patients in plain language, ensuring they understand medications, follow-up appointments, and warning signs
• Confirm that follow-up appointments are scheduled and that the patient has transportation; reschedule or arrange rides when needed
• Reconcile patient-reported medications with discharge records and escalate any discrepancies to clinical staff immediately
• Document all patient interactions accurately and completely in real time, including time spent, interventions delivered, barriers identified, and outcomes achieved
• Track navigation time per patient per month to support accurate billing under CMS Principal Illness Navigation (PIN) codes
• Maintain compliance with CMS billing requirements, HIPAA privacy standards, and program protocols
• Respond constructively to quality audits, chart reviews, and performance feedback

KPI’s You’ll Drive

• Caseload engagement rate
• Enrollment conversion
• Care gap closure
• Appointment adherence support
• Resource connection rate
• Documentation compliance
• Escalation response time
• Patient satisfaction
• 30-day readmission support

Who You Are

• Availability to work Mon - Fri, 9a-6p EST
• Must be located in FL, GA, NC, TN, or TX
• Active Certified Medical Assistant (CMA) or Registered Medical Assistant (RMA) credential from a nationally recognized certifying organization. 1+ years of patient-facing healthcare experience in any of the following settings: medical front office, ambulatory care, primary care, senior care, case management, patient coordination, utilization management, or value-based care programs
• Persuasive and patient-centered communicator — comfortable introducing a new program, addressing hesitation, and guiding undecided patients toward enrollment through a trust-based conversation
• Demonstrated ability to build trust and communicate effectively with older adults and individuals managing serious chronic conditions
• Strong understanding of care coordination principles — you know how healthcare systems work and where patients get stuck
• Comfortable discussing chronic conditions, medications, and treatment plans with patients — you can reinforce clinical guidance without providing medical advice
• Proficient with EHR systems, care management platforms, and digital communication tools — you can navigate multiple systems simultaneously during patient calls
• Self-directed and metric-aware — you manage your own time, track your caseload proactively, and own follow-through without being micromanaged
• Comfortable with ambiguity and rapid iteration — you thrive in environments where processes are still being built and your input matters
• High school diploma or equivalent required; associate's or bachelor's degree in healthcare, social work, public health, or related field strongly preferred

Nice to Have

• Community Health Worker (CHW) certification or training
• Experience working with Medicare-enrolled or dual-eligible populations
• Familiarity with value-based care models, Accountable Care Organizations (ACOs), or Medicare Advantage programs
• Experience conducting post-hospital or post-ED transitional care calls
• Experience with SDOH screening tools or community resource navigation
• Bilingual (Spanish strongly preferred; other languages depending on target population)
• Experience with EHR platforms commonly used in care management (Epic, Cerner, Allscripts, etc.)

Why This Role

• Ground-floor opportunity to help build a program from day one — your work will directly shape how we grow and what best practices we establish
• Close partnership with clinical leadership and program operations — your observations and insights will inform how we scale
• Meaningful, mission-driven work with visible impact — you will see the direct results of your efforts in patients' lives
• Competitive compensation with growth trajectory tied to program expansion and demonstrated performance
• Access to comprehensive training on CMS Principal Illness Navigation (PIN) services, care coordination best practices, and condition-specific education
• Supportive pod-based structure with LVN clinical supervision and peer collaboration

What We Offer

• Health, Dental, and Vision insurance
• Short-term Disability and Life Insurance (100% employer-sponsored)
• Long-term Disability
• Supplemental Life Insurance (employee-sponsored)
• 401(k) Retirement Plan
• 100% Remote
• 6 Paid Holidays
• 10-15 PTO days per year based on tenure