Ambulatory Care Coordinator, Chronic Disease Management

Ambulatory Care Coordinator, Chronic Disease Management

Location: Dallas, TX (Onsite)

We are seeking an Ambulatory Care Coordinator, Chronic Disease Management to serve as the consistent point of contact for patients managing diabetes, heart failure, COPD, and hypertension. This position is a full-time, direct hire opportunity based on-site in Dallas, TX.

This role is best aligned for a patient-facing healthcare professional who wants to prevent hospitalizations and help chronically ill patients live healthier, more independent lives. You will own a panel of patients, close their care gaps, keep them engaged with preventive services, and connect them to the resources that make adherence possible. The ideal candidate builds trust quickly on the phone and in person, and knows how to turn a care gap report into completed appointments.

Responsibilities:

• Conduct outreach to patients with chronic conditions to assess care needs and identify barriers to treatment
• Facilitate scheduling and completion of preventive care visits, laboratory work, and specialist appointments
• Review care gap reports and contact patients to coordinate needed HEDIS and quality measure services
• Promote medication adherence through patient education, refill reminders, and pharmacy coordination
• Connect patients with community resources for transportation, food assistance, and social services
• Document patient interactions, care coordination activities, and follow-up tasks in the EHR
• Collaborate with the care team to develop individualized care plans for complex patients
• Facilitate warm handoffs between hospital discharge, specialist referrals, and home health services
• Enroll eligible patients in disease management, wellness, and value-based care programs
• Track patient engagement and program outcomes, escalating clinical concerns to nursing or provider staff

Qualifications:

• Associate degree in health sciences, medical assisting, or a related field required; bachelor's degree preferred
• Minimum of 2 years of experience in patient care coordination, community health, or a clinical support role required
• Familiarity with chronic disease management for diabetes, hypertension, heart failure, and COPD required
• Experience with EHR systems and care management platforms required
• Knowledge of HEDIS quality measures and value-based care program requirements preferred
• Bilingual English and Spanish communication skills preferred
• Strong interpersonal skills with the ability to build trust with diverse, chronically ill patient populations

Schedule:

• Full-time position
• On-site in Dallas, TX
• Standard business hours, Monday through Friday
• Standard full-time schedule of 40 hours per week

Salary Range: The salary range for this position is approximately $48,000 $62,000 annually ($23.08 $29.81 per hour), based on experience and qualifications.

Interview Process: Selected candidates will participate in a multi-step interview process, including an initial screening followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.