Remote Care Coordinator for CCM & RPM

Vitasora Health USA, Inc.; Acworth (GA); Remote; USD 25,000 - 41,000; Full time

Benefits offered by this job

Medical, vision, and dental coverage

401(k) plan

Paid time off

Job summary

Vitasora Health USA, Inc. is seeking a Care Coordinator to join our remote care team and manage CCM and RPM programs. You will engage patients through motivational interviewing, develop personalized care plans, and ensure a smooth onboarding experience.

You will collaborate with physicians, nurses, social workers, and billing teams, document in the EHR, monitor progress through RPM data, and advocate for patients while maintaining HIPAA compliance.

Qualifications

• Active RN or LPN/LVN compact license required.
• Experience applying motivational interviewing and health coaching in clinical/patient engagement settings.
• Familiarity with CMS CCM guidelines, HIPAA, NCQA standards, and compliance.

Responsibilities

• Conduct monthly outreach calls with patients using motivational interviewing to foster motivation.
• Apply health coaching to guide goal-setting and behavior change.
• Develop CCM care plans based on assessments and priorities.
• Provide tailored education and self-management strategies.
• Address social determinants of health, especially in rural/underserved communities.
• Receive warm hand-offs and deliver seamless onboarding.
• Complete baseline assessments to inform care plans.
• Use motivational interviewing to build rapport and readiness.
• Coordinate with billing/clinical leaders for onboarding and EHR setup.
• Serve as the thread between patients and care teams.
• Monitor progress via RPM data and regular touchpoints; escalate as needed.
• Collaborate with interdisciplinary teams to optimize care outcomes.
• Participate in team huddles and case reviews.

Skills

Motivational interviewing

Health coaching

Patient engagement

EHR proficiency

Telehealth platforms

Remote patient monitoring

Education

Active RN or LPN/LVN compact license

CMA (AAMA) — NCCA-accredited

CCMA (NHA) — NCCA-accredited

NCMA (NCCT) — NCCA-accredited

CMAC (AMCA) — NCCA-accredited

NAHP (NRCMA)

1 year clinical CCM/telehealth experience

Tools

EHR systems

Telehealth platforms

RPM tools

Job description

Vitasora Health USA, Inc. is seeking a Care Coordinator to join our remote care team and manage CCM and RPM programs. You will engage patients through motivational interviewing, develop personalized care plans, and ensure a smooth onboarding experience.

You will collaborate with physicians, nurses, social workers, and billing teams, document in the EHR, monitor progress through RPM data, and advocate for patients while maintaining HIPAA compliance.