RN​/LVN Care coordinator

Care Coordinator/Scheduler (RN/LVN)

Organization: Connected Healthcare Partners (CHP)
Location: Jersey Village, Houston, Texas
Employment Type: Full-Time

Connected Healthcare Partners (CHP) delivers a mobile, relationship-centered model of care designed to improve outcomes for patients living with chronic and complex medical conditions. Through a combination of mobile provider services, chronic care management, transitional care support, and remote patient monitoring, CHP helps patients stay healthier at home while reducing avoidable emergency department visits and hospitalizations.

The Care Coordinator serves as the operational and clinical coordination hub of CHP's chronic care management program and is based primarily at our Jersey Village office. This role acts as the central connection between CHP's Nurse Practitioners, collaborating physicians, patients, caregivers, and internal care teams to ensure care plans, patient engagement activities, and provider schedules operate efficiently and seamlessly.

In addition to managing chronic care management workflows, this position plays a critical role in coordinating Nurse Practitioner schedules and maintaining continuity of care for patients enrolled in CHP programs. The ideal candidate is organized, proactive, clinically knowledgeable, and thrives in a fast-paced, team-oriented healthcare environment.

• Full-time position based in the CHP Jersey Village office.
• Four (4) 10-hour shifts per week.
• Two Care Coordinator positions support this location to provide extended office coverage and ensure continuity of operations throughout the week.
• Shift schedules will be coordinated between both positions to maximize patient access and provider support.

• Coordinate individualized care plans among Nurse Practitioners, collaborating physicians, specialists, and ancillary providers involved in patient care.
• Manage daily operations for Chronic Care Management (CCM), Advanced Primary Care Management (APCM), Remote Patient Monitoring (RPM), and Transitional Care Management (TCM) programs.
• Facilitate patient enrollment, monthly outreach, documentation, and compliance activities for all care management programs.
• Complete post-discharge outreach within required TCM timelines, including patient contact within two business days of discharge and coordination of follow-up appointments within applicable Medicare guidelines.
• Monitor RPM alerts and biometric trends including blood pressure, oxygen saturation, weight, and other clinical indicators for high-risk patients.
• Support scheduling and completion of Annual Wellness Visits and preventive care initiatives.
• Perform medication reconciliation, referral coordination, and care plan updates between provider visits.
• Maintain accurate, timely, and compliant documentation within eClinical
  
  Works (eCW) to support patient care continuity and billing requirements.

• Serve as the primary scheduling resource for CHP Nurse Practitioners using the organization's scheduling platform.
• Coordinate daily and weekly provider routes to optimize efficiency while balancing geography, visit type, urgency, and patient needs.
• Manage same-day schedule changes, cancellations, rescheduling requests, and appointment backfills to maximize provider productivity and minimize travel inefficiencies.
• Maintain accurate scheduling records and communicate schedule updates promptly to providers, patients, and caregivers.
• Coordinate scheduling handoffs and office coverage with the second Care Coordinator assigned to the Jersey Village office to ensure uninterrupted operational support.

• Serve as the primary point of contact for patient and caregiver questions between provider visits.
• Educate patients and families regarding CHP services, chronic disease management, medications, and care plans.
• Promote patient engagement and adherence through relationship-based communication and proactive outreach.
• Support efforts to reduce avoidable emergency department utilization, hospital admissions, and readmissions.

• Serve as a professional point of contact for occasional interactions with hospitals, skilled nursing facilities, home health agencies, physician offices, and health plan partners as directed by CHP leadership.
• Maintain positive working relationships with referral sources and community partners.
• Support organizational growth initiatives through exceptional service and communication.

• Maintain compliance with HIPAA, CLIA requirements, Medicare guidelines, and all CHP policies and procedures.
• Track quality metrics including readmission risk, care management participation, and patient engagement outcomes.
• Participate in team meetings, quality assurance initiatives, chart reviews, and process improvement activities.
• Support operational…