Clinical Services Coordinator

🔥 13 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Medical Home Network

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2009

⚕️ Healthcare Insurance

🏥 Healthcare

🌍 Social Impact

Healthcare Insurance • Healthcare • Social Impact

Medical Home Network is a public benefit corporation dedicated to transforming healthcare in the safety net and fostering healthier communities. By partnering with federally qualified health centers across the United States, MHN empowers these centers to thrive under value-based care, ensuring they deliver high-quality medical services to underserved populations, including Medicaid, Medicare, and dual-eligible individuals. Their comprehensive care model integrates medical, behavioral, and social services, focusing on building trust and understanding within the communities they serve.

📋 Description

• Conduct proactive patient outreach for Annual Wellness Visits, Timely Follow-Up/Transitions of Care, preventive screenings, care management, chronic disease management, and other clinical initiatives • Schedule, coordinate, and confirm patient appointments; address barriers to care and improve appointment adherence • Coordinate services across primary care, specialty care, behavioral health, and community-based organizations • Build relationships with patients, caregivers, providers, and community partners • Provide patient education, reinforce care plans, and support self-management • Help patients navigate healthcare services, insurance resources, transportation, and community supports • Use EMR, population health registries, Agentic AI tools, and reporting platforms to identify outreach and quality-improvement opportunities • Support Annual Wellness Visit workflows, preventive care initiatives, quality measures, and value-based care programs • Assist with health risk assessments, PHQ-9s, and social determinants of health screenings • Monitor patient work queues and outreach lists • Conduct outreach after emergency department visits, hospital admissions, and other care transitions • Coordinate post-discharge appointments, medication reconciliation or review, referrals, and follow-up • Escalate clinical, behavioral health, or social concerns to licensed clinicians or appropriate care-team members • Collaborate with providers and interdisciplinary teams to improve patient engagement, reduce care gaps, and achieve quality goals • Participate in quality improvement, workflow optimization, new clinical program implementation, onboarding, training, and best-practice sharing • Maintain accurate EMR and care-management documentation and ensure compliance with policies, regulations, privacy standards, and documentation guidelines • Use AI-assisted patient engagement tools and digital solutions to improve workflow efficiency and patient engagement • Monitor outreach documentation for performance reporting and quality metrics

🎯 Requirements

• 3 years of work experience in care coordination or care/case management, patient outreach, and connecting to community resources • Bilingual in Spanish and fluent in medical terminology • Experience in safety-net or public health hospitals, Federally Qualified Health Centers (FQHCs), academic medical centers, ambulatory care, physician groups or professional practices, community mental health centers, substance use treatment settings, or outpatient mental health services • Current state licensure as an RN, LPN, LSW, or LCSW is a plus; additional state licensure may be required in any state where the employee provides patient care, including virtual or in-person care • Experience engaging patients with chronic illnesses and needs related to behavioral health and multiple social factors affecting health outcomes • Knowledge and experience working with Medicaid and Medicare populations and in value-based care desirable

🏖️ Benefits

• Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery. • Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare. • Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k. • Fitness reimbursement, commuter benefits, and tuition assistance. • Paid time off, sick time, and 12 paid holidays. • Fully Remote Schedule