Care Concierge, US Remote

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.

Responsibilities

• 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
• Conduct structured SDOH screenings using validated tools to identify barriers such as food insecurity, housing instability, transportation challenges, and financial strain
• Connect patients with appropriate community resources, benefits programs, and social services to address identified needs
• Follow up to confirm patients were able to access resources and troubleshoot barriers when connections fail
• Build and maintain a regional resource directory, updating it as programs and eligibility requirements change
• 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 — Consistent outreach to all assigned patients within established cadence
• Enrollment conversion — Patients successfully consented and enrolled following the Welcome Visit
• Care gap closure — Identified gaps resolved or actively in progress each month
• Appointment adherence support — Follow-up appointments confirmed and transportation arranged for patients post-transition
• Resource connection rate — Patients with identified SDOH needs successfully connected to community resources or benefit programs
• Documentation compliance — All patient interactions documented in real time with no incomplete or late encounter notes
• Escalation response time — Concerns escalated to supervising LVN same day they are identified
• Patient satisfaction — Positive experience reflected through periodic program feedback and check-in surveys
• Thirty-day readmission support — Proactive monitoring and outreach for high-risk patients post-discharge, contributing to reduction in avoidable readmissions
• Productivity — Caseload managed with consistent daily and weekly output across outreach attempts, follow-ups, and documentation — volume and quality of activity are both accounted for

Requirements

• Availability to work Monday - Friday 9am - 6pm EST with no restrictions
• Must be located in: FL, GA, NC, TN, or TX
• Must have an 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

Qualifications

• 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
• Prior 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.)

Benefits

Competitive compensation

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 / No Travel Required

6 Paid Holidays

PTO: 10-15 days per year based on tenure milestones