Care Coordinator

Vitasora Health is redefining how chronic care is delivered in America. We connect patients, providers, and payers through a technology-driven platform built around RPM, CCM, and telehealth, making proactive, continuous care accessible beyond the clinic. Joining Vitasora means being part of a mission-driven team that is not just responding to the future of healthcare, we are building it. Vitasora Health is an Equal Opportunity Employer (EOE) and does not discriminate based on race, color, religion, gender, sexual orientation, national origin, disability, or veteran status. We are committed to fostering an inclusive and diverse workplace that reflects the communities we serve. What Vitasora Health Offers We offer a competitive compensation package including comprehensive medical, vision, and dental coverage, a 401(k) plan, and paid time off. You'll join a collaborative, high-energy environment where innovation is encouraged, contributions are recognized, and careers grow alongside a company shaping the future of chronic care. Position Overview The Onsite Care Coordinator is a clinical cornerstone of Vitasora Health's care team, working face to face with patients in a clinic setting to manage the ongoing health needs of those enrolled in Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. Based at our main clinic location, this role meets with patients in person during their clinic visits, delivers hands‑on device setup and education, and builds the trusting relationships that support lasting behavior change for patients managing chronic conditions such as cardiovascular disease, diabetes, obesity, and respiratory challenges. This role combines clinical expertise with advanced patient engagement skill, including motivational interviewing and health coaching. The Onsite Care Coordinator works from our main site location and travels to other local clinic locations as needed to meet patients where they receive care. Guided by our values of Empathy First, Relentless Advocacy, Radical Simplicity, and Shared Growth, the Onsite Care Coordinator delivers care that begins in the clinic and never stops. This position is performed in person at our main clinic location during scheduled clinic hours. Regular travel (approximately 5 - 30 minute travel) to other local clinic sites is required as business and patient needs dictate; travel schedules will be communicated in advance. Reliable transportation, a valid driver's license, and current auto insurance are required for travel between clinic locations. Monday to Friday during clinic operating hours: 8:00 AM – 4:30 PM or 9:00 AM – 5:30 PM (local time) This role cannot be performed remotely . This role requires flexibility in scheduling based on business and clinic needs, which will be communicated well in advance. Team members may be asked to adjust working hours, including early mornings, evenings, or occasional weekends, to support patient care goals, program deadlines, or operational demands. A willingness to work flexible hours is an important part of this role. Core Responsibilities In-Clinic Patient Engagement and Health Coaching Meet with assigned patients face to face in the clinic setting, using motivational interviewing techniques including open-ended questions, reflective listening, affirmation, and summarizing to foster intrinsic motivation and support self-directed health goals. Apply health coaching principles to guide patients through goal-setting, behavior change planning, and accountability, meeting each patient where they are in their readiness to change. Develop and regularly update individualized CCM care plans based on comprehensive patient assessments, personal values, and stated health priorities. Provide tailored health education and self‑management strategies for chronic conditions using plain language and culturally responsive communication. Address social determinants of health including economic, environmental, and social barriers that impact patient engagement and care access, particularly in rural and underserved communities. Conduct telephonic follow-up and outreach between clinic visits to maintain engagement and monitor progress. Patient Onboarding and Device Setup Meet newly enrolled patients in person during their clinic visits and deliver a seamless, white glove onboarding experience that establishes trust and sets the foundation for the ongoing care relationship. Provide hands‑on setup, demonstration, and education for RPM devices, ensuring each patient leaves the clinic confident in using their equipment. Complete baseline assessments covering health history, medications, social determinants, and patient goals to inform initial care plan development. Use motivational interviewing during onboarding conversations to build rapport, assess readiness, and establish early engagement. Partner with billing, clinical leadership, and referring providers to ensure accurate onboarding and seamless EHR setup. Care Coordination and Interdisciplinary Collaboration Serve as the connective thread between patients and their broader care teams, working alongside clinic physicians, nurses, social workers, and specialists on site. Monitor patient progress through remote monitoring data and regular touchpoints and elevate clinical concerns to appropriate providers using structured communication protocols. Collaborate with interdisciplinary teams at each clinic location to co‑develop care strategies, align on shared goals, and optimize patient outcomes across the care continuum. Participate in team huddles and case reviews at the main site and partner clinics to stay aligned on program priorities and share insights from patient interactions. Clinical Documentation and Compliance Maintain accurate, timely, and HIPAA‑compliant documentation of all patient interactions, care plans, and clinical observations in the Electronic Health Record system. Ensure adherence to CMS guidelines for Chronic Care Management services, NCQA standards, Joint Commission requirements, and applicable regulations. Track patient engagement metrics, document motivational interviewing and health coaching outcomes, and contribute to reporting on program performance and patient progress. Identify patterns in patient barriers and recommend workflow or care plan improvements to the clinical leadership team. Patient Advocacy and Support Identify and proactively address barriers to care access, connecting patients with community resources, healthcare services, and support networks. Promote culturally competent, patient‑centered care that honors the unique values, preferences, and lived experiences of each individual served. Champion the patient's voice within the care team, ensuring their goals and concerns are heard, respected, and incorporated into clinical decision‑making. This role may require completion of tasks and responsibilities outside of those listed above as business needs evolve. Flexibility and a willingness to contribute beyond defined expectations is an important part of this role. Required Qualifications Must hold at least one of the following, current and in good standing: CMA (AAMA) — NCCA‑accredited CCMA (NHA) — NCCA‑accredited NCMA (NCCT) — NCCA‑accredited CMAC (AMCA) — NCCA‑accredited RMA (AMT) — NCCA‑accredited RMA (AAH) — ANAB/ISO 17024‑accredited Active, unencumbered RN or LPN/LVN license All certifications and licenses must be current and in good standing, and will be verified through primary source before hire. Minimum 1 year of clinical experience in chronic care management, telehealth, primary care, or a related setting; 3 or more years preferred. Ability to work onsite at [Main Clinic Location] and travel to other local clinic locations as needed. Reliable transportation, valid driver's license, and current auto insurance. Demonstrated knowledge of and experience applying motivational interviewing and health coaching techniques in a clinical or patient engagement setting. Proficiency in EHR systems, telehealth platforms, and remote patient monitoring tools. Strong verbal and written communication skills with the ability to engage patients empathetically, navigate objections, and promote behavior change. Familiarity with CMS CCM guidelines, HIPAA regulations, NCQA standards, and applicable compliance requirements. Preferred Qualifications Bilingual proficiency in English and Spanish. Additional languages welcome. Experience working with Medicare and Medicaid patients and managing complex chronic disease populations. Knowledge of social determinants of health and their impact on rural and underserved communities. Prior experience in a clinic, primary care practice, or other in‑person care delivery setting. Proven ability to build rapport quickly and handle sensitive conversations with empathy and professionalism. Physical & Work Requirements Work is performed onsite in a clinical environment, including prolonged periods of standing, walking, and sitting, and regular computer use. Reliable transportation and valid licensure to commute between local clinic locations as needed. Must be able to lift up to 15 pounds at times. Equal Opportunity Employer Vitasora Health USA Inc is an Equal Opportunity Employer (EOE) and does not discriminate based on race, color, religion, gender, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law, including but not limited to gender identity, gender expression, marital status, medical condition, genetic information, ancestry, and age. We are committed to fostering an inclusive and diverse workplace that reflects the communities we serve. #J-18808-Ljbffr Vitasora Health