Care Coordinator II, Care Transitions

Role Overview
Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following hospital discharge. The Care Coordinator II is the operational backbone of the remote interdisciplinary team - executing the coordination tasks that keep NP, RN, and SW Care Manager workflows running smoothly throughout the 30-day TCM episode.
This is a hybrid role. You'll support virtual care operations through scheduling, documentation, outreach, and referral coordination. On occasion you'll go into the field to help patients who need hands-on support to participate in telehealth visits.
This is a ground-floor opportunity. Early team members will help shape workflows, surface gaps, and build a program designed to scale. What You'll Own
• Delegated coordination tasks across the NP, RN Care Manager, and SW Care Manager workflows throughout the TCM episode
• Pre-visit prep: records retrieval, referral status, discharge documentation, and scheduling logistics
• Patient and caregiver outreach, appointment reminders, and telehealth readiness support What You'll Do
• Execute delegated tasks from clinical staff: outreach, records retrieval, referral coordination, appointment scheduling, and visit logistics
• Coordinate follow-up appointments, specialist referrals, home services, transportation, and community-based resources
• Conduct patient and caregiver outreach for scheduling, reminders, telehealth preparation, and post-discharge follow-up
• Support patients and caregivers with telehealth onboarding and technology troubleshooting; perform occasional field visits when patients cannot participate independently
• Track outstanding tasks, referral needs, scheduling barriers, and TCM workflow milestones; escalate clinical concerns to licensed staff promptly
• Document coordination activities, outreach attempts, and scheduling updates in the EMR; maintain accurate tracking of referrals and care coordination milestones
• Participate in interdisciplinary huddles and contribute frontline feedback to workflow improvement as the program scales What Success Looks Like
• Patients and caregivers feel supported and informed throughout the transition process
• Outstanding tasks and documentation are tracked proactively with minimal oversight
• Patients can successfully participate in virtual care with reduced technology barriers
• Coordination activities and milestones documented accurately and on time
• Workflow gaps and operational barriers identified early and surfaced to leadership What You Bring
Required:
• High school diploma or GED required; associate degree or healthcare-related education strongly preferred
• 2+ years of experience in care coordination, home health, health plan care management, patient access, or healthcare operations
• Strong organizational skills with ability to manage concurrent workflows and shifting priorities independently and remotely
• Excellent communication skills with a patient-centered, customer-service-oriented approach
• Comfortable working from home with high accountability and responsiveness across a distributed team
• Comfort navigating multiple technology platforms simultaneously (EMR, scheduling, telehealth, communication tools)
• Valid driver's license, reliable transportation, and active automobile insurance for field visits
• Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Preferred:
• Experience in care management, population health, home health, post-acute care, or transitional care settings
• Experience supporting Medicare, senior, dementia, behavioral health, or medically complex populations
• Background in telehealth, virtual care, or mobile/home-based care delivery
• Strong fit for candidates with combined clinical support and healthcare operations experience - e.g., home health intake staff, transitional care coordinators, or community health workers with practice operations backgrounds Schedule and Work Style
Work Type: Hybrid - primarily remote/work-from-home with occasional field visits
Schedule: Monday-Friday, 8:00 AM - 5:00 PM ET
Travel: Occasional field visits across Montgomery County, MD; must reside within commuting distance of Rockville
Autonomy: High independent ownership of delegated tasks within a close-knit remote team Compensation and Perks
Salary Range: $47,500 - $60,500 annually, commensurate with experience
Key Benefits:
• Medical coverage: DPC model + high-deductible health plan; 100% of employee medical premiums covered
• Dental and vision insurance
• HSA with employer contributions | Company-paid life and disability insurance
• 401(k) with 2% employer match
• 15 days PTO (accrued per pay period, increasing with tenure) | 8 + 1 floating holidays
• Mileage reimbursement: $0.725/mile for travel exceeding 30 miles/day (up to $200/day)
• All devices and technology provided About Avail Health
Avail Health is a Nurse Practitioner-founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit