Ensemble Cin

Description

About the Role:
At Ensemble CIN in Albuquerque, we believe healthcare works best when it meets people where they are. As a Care Coordinator II, you'll be part of a small, mission-driven team helping patients with complex needs stay healthy. You'll build real relationships, coordinate meaningful care, and make a tangible difference-every single day.

Key Responsibilities:

• On site work at Gateway West with Unhoused Senior population/Shelter
• Carry Caseload
• Perform Intakes
• Identify Resource Needs and Assist with Obtaining - housing, transportation, food, clothing, health insurance applications, cell phones, PCP/Specialist Care, etc.
• Goal of Rehousing Seniors
• Work in the Community to network with vendors who can help with resource needs
• Work in the Community to follow up on Seniors rehoused
• Timely and accurate documentation of hours applied to shelter work and EMR documentation
• Manage ongoing care coordination for chronically ill or high-risk patients
• Collaborate with physicians, nurses, and partner providers to develop and monitor care plans
• Track patient outcomes and follow up regularly to ensure goals are met
• Navigate care transitions across hospitals, clinics, and home-based settings
• Advocate for patient needs with empathy, clarity, and persistence
• Document assessments, care activities, and progress in EMR systems
• Participate in interdisciplinary team meetings and case conferences
• Support culturally responsive care and build trust with diverse communities

Requirements

What We're Looking For:

• 2+ years of care coordination, case management, or similar experience
  
• Bilingual in Spanish and English - able to connect with families in both languages
  
• Deep understanding of community-based care models
  
• Strong organizational skills and the ability to juggle multiple priorities
  
• Compassionate communicator who knows how to listen and lead
  
• Comfortable using EMR tools and documenting care accurately
  
• Able to work independently while staying deeply connected to the team
  
• Passion for meaningful, equity-driven work in a value-based care setting
  

Why Join Us:
Ensemble CIN is part of a pioneering movement to reshape healthcare through connection, collaboration, and courage. Backed by CareM Management Services, we serve as the clinical backbone for high-need populations in New Mexico. We offer a supportive team environment, opportunities to grow, and the chance to be part of something truly meaningful.

Our mission is simple but powerful: to bring out the courage in others - whether that's a patient facing a new diagnosis or a teammate finding their voice. If that speaks to you, we hope you'll apply.