The Remote Care Coordinator (Medical Assistant) is responsible for delivering proactive, patient-centered care through Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) programs. Working closely with physicians and care teams, the coordinator monitors patient health, conducts monthly virtual check-ins, educates and motivates patients, coordinates care, and facilitates timely clinical interventions to improve health outcomes.
Key Responsibilities
•Collaborate with providers to understand patients' health conditions and develop individualized CCM care plans.
•Coordinate communication between providers, patients, family members, and care teams.
•Set up and monitor patient-specific vital sign alerts and identify early signs requiring intervention.
•Conduct monthly patient check-in calls and escalate clinical concerns when appropriate.
•Educate and motivate patients to remain compliant with CCM and RPM programs, including achieving CMS compliance requirements (20 minutes of monthly care coordination and 16 days of vital sign readings for RPM).
•Provide support and training for remote monitoring devices and resolve patient-related technical issues.
•Document all patient interactions, monitoring activities, and care coordination accurately.
•Coordinate telemedicine appointments and collaborate with providers for timely interventions.
•Track patient engagement, compliance, and health outcome KPIs.
•Strictly adhere to HIPAA, CMS, and organizational privacy and security policies
Qualifications
- Registered Nurse (RN/LPN/LVN) or Certified/Experienced Medical Assistant (MA/CMA) or equivalent clinical experience.
- Excellent verbal and written communication skills; bilingual (English & Spanish) preferred, but not required.
- Demonstrated ability to conduct professional, empathetic, and engaging patient phone check-ins and build strong patient relationships.
- Highly organized, self-motivated, and capable of working independently in a remote/work-from-home environment.
- Experience in Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Telehealth, or care coordination is highly desirable.
- Strong patient education, care coordination, documentation, and time-management skills.
- Proficient in using Electronic Medical Records (EMRs), remote monitoring devices, and digital healthcare platforms.
- Ability to recognize changes in patient condition and appropriately escalate concerns to the clinical care team.
- Strong problem-solving skills with attention to detail and accuracy in documentation.
- Compassionate, patient-centered mindset with a commitment to improving patient engagement, compliance, and health outcomes.
- Working knowledge of HIPAA regulations and commitment to maintaining patient privacy and confidentiality.
- Basic computer proficiency, including Microsoft Office/Google Workspace and web-based communication tools.