Care Coordinator

Vitasora Health; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

Vitasora Health is seeking a Care Coordinator to support chronic care management and remote patient monitoring for patients across various conditions. The role emphasizes building rapport, conducting onboarding, and guiding patients through goal setting and self-management with motivational interviewing.

The Care Coordinator will collaborate with interdisciplinary teams, monitor progress via RPM data, and contribute to higher quality outcomes in a remote care setting.

Qualifications

• Experience engaging patients to support self-management and behavior change.
• Ability to develop individualized CCM care plans and document progress.
• Familiarity with RPM workflows and collaborating with care teams.

Responsibilities

• Engage patients monthly using motivational interviewing to support goals.
• Develop and update CCM care plans based on assessments and priorities.
• Coordinate care with physicians, nurses, social workers, and specialists.
• Facilitate onboarding and ensure seamless EHR setup and referrals.

Skills

Patient engagement

Health coaching

Motivational interviewing

Care coordination

Remote patient monitoring

Tools

EHR systems

Job description

The Care Coordinator is a clinical cornerstone of Vitasora Health's remote care team, responsible for managing the ongoing health needs of patients enrolled in Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. This role combines clinical expertise with advanced patient engagement skill, including motivational interviewing and health coaching, to build meaningful and trusting relationships that support lasting behavior change and improved outcomes for patients managing chronic conditions such as cardiovascular disease, diabetes, obesity, and respiratory challenges. Care Coordinators receive warm hand-offs of newly enrolled patients and are responsible for delivering a seamless, white glove onboarding experience that sets the tone for the ongoing care relationship. Guided by our values of Empathy First, Relentless Advocacy, Radical Simplicity, and Shared Growth, the Care Coordinator delivers care that goes beyond the clinic.

Core Responsibilities

Patient Engagement and Health Coaching

• Conduct monthly outreach calls with assigned patients 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.
• Receive warm hand-offs of newly enrolled patients from the enrollment team and deliver a seamless, white glove onboarding experience that establishes trust and sets the foundation for the ongoing care relationship.
• 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.

Patient Onboarding

• Receive warm hand-offs of newly enrolled patients from the enrollment team and deliver a seamless, white glove onboarding experience that establishes trust and sets the foundation for the ongoing care relationship.
• 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, facilitating warm hand-offs and timely communication with physicians, nurses, social workers, and specialists.
• 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 to co-develop care strategies, align on shared goals, and optimize patient outcomes across the care continuum.
• Participate in team huddles and case reviews to stay aligned on program