Care Coordinator, MA (Bilingual)

Evergreen Nephrology, LLC.; San Diego (CA); Remote; USD 45,000 - 52,000; Full time

Benefits offered by this job

Paid time off 4 weeks

Medical, dental, vision, life

401(k) with 4% match

Educational reimbursement

Parental leave

Job summary

Evergreen Nephrology, LLC. is hiring a Chronic Care Management (CCM) Care Coordinator to support patients with CKD, hypertension and related conditions. The role emphasizes outreach, care plan maintenance, compliance and collaboration with remote clinical teams.

You will work under clinical supervision, handling high-volume outreach, eligibility checks, and documentation in CCM and EHR systems, with a Pacific Time schedule while fully remote.

Qualifications

• Certified Medical Assistant with 1–3 years healthcare experience.
• Experience in chronic disease or nephrology preferred.
• Strong clinical assessment, documentation and communication skills.
• Able to work with EHR and CCM platform simultaneously.
• Self-driven, metric-minded with reliable workflow discipline.

Responsibilities

• Support CCM patient enrollment and onboarding activities.
• Verify eligibility and ensure consent documentation before outreach.
• Maintain patient engagement and document interactions in CCM/EHR.
• Coordinate referrals, follow-up appointments and care transitions.
• Conduct high-volume outbound outreach (text/phone) and track engagement time.
• Escalate issues to licensed clinical staff and ensure HIPAA compliance.

Skills

Certified Medical Assistant

Healthcare experience

Nephrology experience

Clinical assessment

Two systems (EHR CCM)

Workflow management

MS Office (Outlook/Teams)

Tools

EHR systems

CCM platform

Job description

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.

Your Role

The Evergreen Chronic Care Management (CCM) Care Coordinator supports proactive care coordination services for patients with complex chronic conditions, including chronic kidney disease (CKD), hypertension, diabetes, cardiovascular disease, and related comorbidities. Working under Evergreen’s clinical supervision, the Care Coordinator conducts patient outreach, creates, maintains, and reinforces established care plans, supports documentation compliance, and coordinates communication between patients, providers, and healthcare partners.

This role is outreach-driven and operationally focused, requiring strong organization, patient communication skills, and the ability to manage a high-volume patient panel. Experience supporting nephrology or CKD patient populations is strongly preferred.

The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.

While this position is fully remote, you must be able to work 8:00am – 5:00pm in the pacific time zone.

Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Support CCM patient enrollment and onboarding activities.
• Verify eligibility based on Evergreen and payer program guidelines.
• Ensure patient consent documentation is completed prior to outreach.
• Proactively maintain patient engagement regularly.
• Identify inactive or non-engaged patients and escalation appropriately.
• Patient Outreach & Engagement
  • Conduct text & telephonic outreach to enrolled CCM patients weekly.
  • Achieve required engagement time standards aligned with Medicare CCM billing requirements.
  • Support achievement of required engagement time for billing compliance.
  • Reinforce provider-directed care plans during patient interactions.
  • Identify barriers to adherence including medication access, transportation, or social needs.
• Expected activities include:
  • High-volume outbound patient calling and texting.
  • Follow-up outreach attempts.
• Document patient interactions accurately within the CCM patient management platform and EHR systems.
• Track engagement time consistent with Medicare CCM billing requirements.
• Maintain audit-ready documentation standards.
• Ensure HIPAA and PHI compliance.
• Patient Care Coordination & Clinical Workflow
  • Facilitate patient access to their referring provider and clinical staff.
  • Support care transitions following hospitalizations or ED visits.
  • Coordinate referrals and follow-up appointments.
  • Escalate symptom concerns or medication issues to licensed clinical staff.
• Preferred experience includes:
  • Chronic kidney disease patient populations.
  • Dialysis patient coordination.
  • Medication adherence monitoring.
  • Kidney transplant or specialty referrals.
• Utilize CCM platform and EHR systems daily.
• Collaborate with remote clinical and operational teams.

Required Qualifications

• Certified Medical Assistant
• 1–3 years healthcare experience
• Chronic disease or nephrology experience is preferred.
• Strong clinical assessment, communication, and documentation skills.
• Comfortable working in two systems (EHR + CCM platform) simultaneously.
• Ability to manage a structured, metric-driven workflow with reliability.
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote environment:
  • Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
  • Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Experience in chronic disease management
• Prior work in virtual care, remote nursing, or telehealth programs.
• Familiarity with CCM regulatory requirements.
• Strong patient education and motivational interviewing skills.

Compensation

The pay range for this role is $45,000 to $52,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

This role is also eligible for a bonus.

Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:

• Paid time off starting at 4 weeks for full-time employees
• 12 paid holidays per year
• Medical, dental, vision and life insurance, including an HSA with employer match
• Reimbursement for continuing medical education for eligible roles
• A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
• Paid parental leave
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.

If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at [e-mail] .

Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.

As set forth in Evergreen Nephrology’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.