Care Coordinator & Onboarding Specialist- Onsite Area
Listed on 2026-08-01
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Healthcare
Community Health, Healthcare Nursing, Patient Care Technician
Description
Care Coordinator
Reports to:
Care Manager
Location:
Cypress, TX Katy, TX, Sealy, TX & 3 Houston locations
Status:
Full-time
Jobs Available: 6
Start Date:
September 1, 2026
Summary of Position:
The Care Coordinator & Onboarding Specialist supports patients by gaining consent for various programs such as Chronic Care Management (CCM), Principal Care Management and Remote Patient Monitoring. Primarily the consent will be done face-to- face with the patient but may involve telephonic consent s role involves training patients on how to use various medical devices at the clinic before the patient uses the device(s) in their home setting to send readings back to the clinic.
Example of the devices to be used for the patients would be a blood pressure monitor, weight scale, glucometer or pulse oximeter. Eventually this role will transition to coordinating care services and helping patients follow their care plans. The role will eventually evolve to include regular patient outreach, identifying and addressing gaps in care, coordinating services with providers and community resources, and documenting activities in the Care Vitality platform.
The Care Coordinator works closely with providers, care managers, and internal teams to ensure continuity of care and support positive patient outcomes.
Responsibilities- Initially, the role focus on gathering patients consent for various care management and remote monitoring programs and setting up and training patients to use specific medical devices to be used in their home.
- Review and update patients’ current allergy and medication profiles. Support patient self-management of medications within the Care Coordinator scope.
As months progress as the patients for the client are onboarded this role will transition to the following?
- Conduct monthly follow-up with patients by reviewing the patient-centered care plan based on physical, mental, cognitive, psychosocial, functional, and environmental assessments, as well as an inventory of available resources.
- Provide Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) patients with appropriate educational materials and resources to support health education, self-management, and lifestyle improvement.
- Identify patients with gaps in preventive health services and assist with scheduling required screenings or diagnostic tests with their providers.
- Review and update patients’ current allergy and medication profiles, assess adherence and potential interactions, and communicate concerns to the patient and providers as appropriate. Support patient self-management of medications within the Care Coordinator scope.
- Engage patients through monthly care plan reviews that promote healthy lifestyles, close gaps in care, and reduce unnecessary emergency department utilization and hospital readmissions. Coordinate care with patients, caregivers, primary care providers, specialists, community resources, behavioral health partners, and other health plan or system departments as appropriate.
- Document all care coordination activities in the or Care Vitality platform and possibly the Electronic Health Record if requested by the client in accordance with Care Vitality standards, including required time elements, and identify trends or opportunities for improvement based on patient, provider, and system interactions.
- Health Risk Assessments (HRA), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) may be incorporated into the role as program needs evolve.
- Escalate patients requiring reassessment, care plan revision, or higher-level clinical intervention to the assigned Care Manager in a timely manner.
- Transitional Care Management Services may need to be provided in any given month as part of the scope of services
- Provide transportation assistance if needed
- Perform other duties as assigned.
Qualifications:
To successfully perform this role, an individual must be able to perform the essential duties satisfactorily. The qualifications listed below represent the knowledge, skills, and abilities required for the Care Coordinator role.…
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