Care Coordinator - I-SNP (Temp to Hire)

About Avail Health 

Avail Health is a Nurse Practitioner–founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient–provider relationship to enable nurse-led virtual and mobile care models. As a fast-growing organization, we are building durable clinical infrastructure to support innovative care programs across multiple states, with a focus on improving outcomes for complex and underserved senior populations. For more information visit availhealthcare.co

About the Role 

The Care Coordinator (CC) – I-SNP is a clinical support and care coordination role responsible for enabling front-line clinicians to deliver high-quality psychiatric and medical care to Medicare Advantage Institutional Special Needs Plan (I-SNP) members residing in long-term care skilled nursing facility settings. The CC functions as a hybrid front and back office clinical support partner across Avail Health’s mobile and telehealth settings of care. 

The majority of the role is focused on front and back-office support, including managing inbound communications, coordinating care, and supporting clinical workflows. The CC serves as a central point of contact for the practice team, managing inbound calls, portal messages, and faxes from patients, caregivers, and facility staff, and ensuring timely, accurate routing and resolution of requests. 

On the back-office side, the CC supports virtual and mobile Nurse Practitioners (NPs) and Registered Nurses (RNs) through scheduling, visit preparation, documentation support, and coordination of follow-up care. This includes close collaboration with the behavioral health team, including a Psychiatric Nurse Practitioner (PMHNP) and Community Health Workers (CHW), to ensure seamless, integrated care delivery across medical and behavioral health needs. 

While this is primarily a remote coordination role, the CC may also provide occasional in-person support in the field to facilitate telehealth visits when needed. This includes assisting with technology setup, ensuring visit readiness, and supporting patient engagement during telehealth encounters in their facility. 

The I-SNP population is clinically and socially complex, with a high burden of behavioral health conditions, cognitive impairment, comorbid medical illness, and significant social determinants of health needs. The CC plays a critical role in supporting efficient, coordinated care delivery, allowing clinicians to operate at the top of their license while ensuring a high-quality patient and caregiver experience. 

This role operates within Avail Health’s integrated, team-based care model and serves as a key operational and coordination hub across disciplines, supporting both the execution and scalability of the program. 

Location & Work Environment 

This is a hybrid role requiring residence within Maryland , with regional coverage spanning multiple skilled nursing facilities. There will be some travel throughout the state. Standard hours are Monday through Friday, 8:00 AM – 5:00 PM EST. Remote work requires a reliable high-speed internet connection and a dedicated, HIPAA-compliant workspace. 

Key Responsibilities 

Clinical Support & Care Coordination 

• Manage inbound communications for the practice and routing to the appropriate team members, ensuring timely follow-up and resolution. 

• Support virtual and mobile Nurse Practitioners (NPs) and Registered Nurses (RNs) with scheduling, visit preparation, and follow-up coordination. 

• Coordinate care plans, referrals, and longitudinal follow-up across medical and behavioral health needs. 

• Collaborate closely with the behavioral health team to ensure integrated, team-based care delivery. 

• Manage and optimize provider schedules, including behavioral health and medical visits, follow-ups, and facility coordination. 

• Ensure alignment between provider availability, patient needs, and facility workflows to maximize efficiency and access to care. 

Documentation, Quality & Operational Excellence 

• Complete accurate, timely, and compliant documentation within the electronic health record (EHR). 

• Support clinical workflows, quality initiatives, and adherence to regulatory and organizational standards. 

• Identify workflow gaps and escalate opportunities for process improvement to enhance team efficiency and patient experience. 

Telehealth & Mobile Visit Support 

• Provide real-time support during telehealth visits, including troubleshooting, documentation assistance, and coordination of next steps. 

• Occasionally provide in-person support to facilitate telehealth visits, assist with technology, and support patient engagement when needed. 

Required Qualifications 

• High school diploma or equivalent required; Medical Assistant certification or Associate’s degree a plus. 

• Minimum 2 years of experience in a clinical support, medical assistant, care coordination, or healthcare operations role. 

• Experience supporting behavioral health or complex medical populations preferred. 

• Strong organizational, communication, and technology skills. 

Preferred Qualifications 

• Experience in telehealth, mobile care, or long-term care settings. 

• Behavioral health care coordination and/or behavioral health medical practice experience. 

What Success Looks Like 

• Seamless communication hub: Inbound calls, messages, and faxes are addressed promptly with clear, timely resolution and minimal escalation.

• Strong care coordination: Referrals, follow-ups, and care plans—across medical and behavioral health—are completed accurately and without gaps.

• Reliable telehealth execution: Occasional in-person support effectively enables patient participation when needed.

• Optimized scheduling: Provider schedules are well-managed, balancing access, efficiency, and facility coordination.

• High-quality documentation & compliance: EHR documentation is timely, accurate, and meets organizational and regulatory standards.

• Proactive problem-solving: Workflow gaps are identified early, with solutions that improve team efficiency and patient experience. 

Compensation & Benefits 

• Total Salary: $52,000 to $60,000; commensurate with experience 

• Retirement: 401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements 

• Performance Bonus: Employees may be eligible for a discretionary performance bonus based on individual performance, role-specific metrics, and overall company performance. Bonus structure and targets vary by role and are not guaranteed. Employees must be actively employed on the payout date to receive any bonus. 

• Annual Compensation Review: Compensation is reviewed annually and may be adjusted based on performance, market data, and organizational factors. Adjustments are not guaranteed. 

• Mileage Reimbursement: $0.725 per mile for travel exceeding 30 miles per day, up to $200 per day. 

• Benefits Package: Comprehensive benefits include medical, dental, and vision coverage. The company offers a Direct Primary Care (DPC) model paired with a high-deductible health plan and covers 100% of employee medical premiums, with dependent coverage subsidized. Additional benefits include company-paid life and disability insurance, and employer contributions to a Health Savings Account (HSA). 

• Paid Time Off: Employees accrue 15 days of paid time off annually, increasing with tenure. PTO accrues per pay period. 

• Holidays: 8 paid company holidays plus 1 floating holiday annually. 

• Retirement: 401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements 

Additional Requirements 

• Valid driver’s license, reliable transportation, and active automobile insurance; must be able to travel daily within the assigned region and provide proof of insurance upon request 

• Ability to meet privileging, background check and screening requirements (employment contingent upon completion) 

• Compliance with all applicable federal, state, and organizational regulations governing clinical practice and community health work 

Support and Resources

• Avail Health provides all necessary devices and technology for clinical and telehealth-related activities