Care Coordinator - Primary Care Outreach & Transitions of Care

Care Coordinator – Primary Care Outreach & Transitions of Care

*Previous work in a primary care setting, with experience scheduling patients, managing care gaps, and transitions of care are required for this position.*

Company Description

HealthHelper partners with healthcare practices nationwide, utilizing a combination of data, AI automation, and people to support efficient, high-quality patient communication and care coordination, while off-loading tasks from overworked providers and practice staff. HealthHelper works behind the scenes, offering healthcare organizations solutions for inbound overflow call management, schedule optimization, care gap closure, transitions of care, and referral management.

Opportunity

We are looking for a highly organized, hands-on Care Coordinator to join our remote team. The role plays a critical part in helping primary care patients access preventive care services, and in supporting patients recently discharged from the hospital or emergency department.

This is an execution-focused position for someone who is dependable, comfortable working independently, communicates well with patients and practice staff, and can recognize when something needs additional attention or escalation. The ideal candidate may be someone who has worked as a Medical Assistant in a primary care office, particularly someone who enjoyed the administrative, patient communication, scheduling, and care coordination aspects of the role.

Position Title - Care Coordinator – Primary Care Outreach & Transitions of Care

Reports To - Director of Operations

Location - This is a remote, work-from-home position, candidates in the Eastern/Central Time Zones are strongly preferred

Works in Collaboration With - Director of Operations, Chief Medical Officer, Chief Product Officer, Team Leads, and peers internally, as well as customer office staff - primarily Practice Administrators, Nurse Care Managers, and Medical Assistants at partner primary care practices.

Position Summary

The Care Coordinator runs both automated and manual outreach campaigns to engage and schedule patients for preventive services, important screenings, primary care visits, and post hospital follow ups. This position is responsible for ensuring patients are contacted promptly, scheduled for services within the appropriate time-frame, and that any clinical or social barriers to care are identified and escalated appropriately.

This role offers growth potential, including opportunities to evolve into a Team Lead position. The Coordinator will also help refine our outreach processes and gather feedback from patients and customers to continuously improve our transitions of care programs.

Responsibilities

• Monitor care gap and quality metric lists to guide and initiate patient outreach campaigns for care gap closure
• Monitor daily hospital and ED discharge lists and initiate patient outreach campaigns within required timeframes
• Conduct automated and manual outbound call/text campaigns to patients 
• Schedule timely primary care/specialty follow-up appointments, screenings, and preventive services 
• Ask patients recently discharged from inpatient stays or ED visits basic questions to confirm understanding of discharge instructions, medication changes, and assess follow-up needs
• Identify and escalate patient clinical or logistical issues (e.g., medication confusion, transportation barriers) to the appropriate PCP care team members
• Work in multiple EHRs (Electronic Health Records) and other technology platforms
• Document outreach outcomes accurately in both internal databases and customer EHRs
• Respond to inbound patient or practice inquiries related to care gap closure or post-discharge care
• Complete assigned work consistently and within expected timeframes
• Participate in quality improvement initiatives related to quality metrics, ED utilization, hospital readmission reduction, and care continuity
• Collaborate with leadership to improve workflows, outreach messaging, and overall program effectiveness

Required Qualifications

• Primary Care Experience (REQUIRED): Experience working in a primary care medical office, healthcare setting, call center, scheduling environment, or similar patient-facing role
• Experience with care gap or quality work and hospital and ED discharge follow-up are imperative 
• Technology Experience (REQUIRED): Strong computer skills and willingness to learn new technology. Comfort using EHR systems, communication technologies, population health tools, care management platforms, and other technology tools
• Conversational and written Spanish proficiency (REQUIRED) : You should be comfortable having a basic phone and/or text message conversation with Spanish-speaking patients about appointments, follow-up care, and next steps.
• Strong verbal and written communication skills
• Ability to follow established workflows and protocols
• Ability to work independently and reliably in a remote environment
• High school diploma/GED or equivalent work experience

Preferred Experience

• Previous experience as a Medical Assistant in a primary care practice
• Experience with EHRs such as eClinicalWorks, Athenahealth, Epic, NextGen, or similar systems
• Experience scheduling primary care appointments
• Experience communicating with patients by phone and/or text
• Experience working in a remote healthcare environment