Phamily
Community Care Coordinator (Remote) – Text-Based APCM Program
Phamily, Washington, District of Columbia, us, 20022
Community Care Coordinator (Remote) – Text-Based APCM Program
Join to apply for the
Community Care Coordinator (Remote) – Text-Based APCM Program
role at
Phamily Community Care Coordinator (Remote) – Text-Based APCM Program
Join to apply for the
Community Care Coordinator (Remote) – Text-Based APCM Program
role at
Phamily Job Title: Community Care Coordinator (Remote) – Text-Based APCM Program
Department:
Clinical Operations
Location:
Remote (Candidates must be willing to work within CST, PST or EST time zone)
Reports To:
Associate Director of Clinical Services
Position Type:
Full-Time
About The Role
We are seeking a compassionate and resourceful Community Care Coordinator to join our virtual care team. This role is ideal for a Licensed Medical Assistant (MA) or Licensed Practical Nurse (LPN) with strong communication skills and a heart for community impact. In this role, you’ll support patients transitioning from hospital to home, assist with identifying community resources, and help reduce gaps in care through thoughtful, timely, and tech-enabled outreach.
As a vital member of our Advanced Primary Care Management (APCM) team, you will provide post-discharge follow-up (TCM), coordinate community support services, and address non-clinical barriers to care for patients with chronic conditions. You will work under the direction of the Associate Director of Clinical Operations and collaborate closely with care managers, RNs, social workers, and providers to ensure continuity of care and successful patient outcomes.
Prioritizing hires in New Mexico, Illinois and Washington in initial launch. Candidates in other locations may apply, but applications will be held until there are additional resources needed outside of the initial target areas.
Key Responsibilities
Conduct post-discharge outreach within 48 hours of hospital or ED discharge for TCM (Transitional Care Management) follow-up. Identify and help coordinate social support services: food, housing, transportation, behavioral health, and financial assistance. Assist patients with after-care coordination, such as scheduling follow-up appointments and addressing medication access issues. Use a secure text-based platform to engage patients, respond to needs, and escalate care concerns to the appropriate clinical team member. Monitor hospital admission and discharge reports and proactively reach out to enrolled patients. Support patients with navigation of health systems, including insurance questions and provider access. Participate in daily team huddles, report progress, and track patient engagement and task completion. Document all activities in EHR/Phamily platform in real-time according to compliance standards. Escalate critical needs to licensed social workers, nurses, or physicians based on escalation guidelines. Support quality goals such as reducing readmissions, improving care coordination, and closing SDOH gaps.
Key Skills & Qualifications
Required: Active LPN or CMA/RMA certification in good standing Preferred: Experience in social work, case management, hospital navigation, or transitional care coordination 2+ years of experience in clinical, community health, or post-acute care settings Comfortable using text-based health platforms, EMRs, and digital communication tools Strong knowledge of community resources, health equity, and SDOH Critical thinking skills and ability to triage needs with urgency and empathy Excellent written communication and time management Bilingual (Spanish/English) a plus but not required
Schedule & Work Environment
Full-time, Monday–Friday Flexible remote schedule across CST, EST, or PST time zones 1-hour lunch break, daily huddles with manager/team Ongoing support from a multidisciplinary care team
Why Join Us?
Be a part of a mission-driven organization focused on health equity and innovative digital care Collaborative, diverse, and growth-focused culture Opportunities for professional development and internal promotion Competitive compensation and benefits package Professional development support Be part of redefining how care is delivered—one text at a time
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Other Industries Hospitals and Health Care Referrals increase your chances of interviewing at Phamily by 2x Get notified about new Care Coordinator jobs in
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Join to apply for the
Community Care Coordinator (Remote) – Text-Based APCM Program
role at
Phamily Community Care Coordinator (Remote) – Text-Based APCM Program
Join to apply for the
Community Care Coordinator (Remote) – Text-Based APCM Program
role at
Phamily Job Title: Community Care Coordinator (Remote) – Text-Based APCM Program
Department:
Clinical Operations
Location:
Remote (Candidates must be willing to work within CST, PST or EST time zone)
Reports To:
Associate Director of Clinical Services
Position Type:
Full-Time
About The Role
We are seeking a compassionate and resourceful Community Care Coordinator to join our virtual care team. This role is ideal for a Licensed Medical Assistant (MA) or Licensed Practical Nurse (LPN) with strong communication skills and a heart for community impact. In this role, you’ll support patients transitioning from hospital to home, assist with identifying community resources, and help reduce gaps in care through thoughtful, timely, and tech-enabled outreach.
As a vital member of our Advanced Primary Care Management (APCM) team, you will provide post-discharge follow-up (TCM), coordinate community support services, and address non-clinical barriers to care for patients with chronic conditions. You will work under the direction of the Associate Director of Clinical Operations and collaborate closely with care managers, RNs, social workers, and providers to ensure continuity of care and successful patient outcomes.
Prioritizing hires in New Mexico, Illinois and Washington in initial launch. Candidates in other locations may apply, but applications will be held until there are additional resources needed outside of the initial target areas.
Key Responsibilities
Conduct post-discharge outreach within 48 hours of hospital or ED discharge for TCM (Transitional Care Management) follow-up. Identify and help coordinate social support services: food, housing, transportation, behavioral health, and financial assistance. Assist patients with after-care coordination, such as scheduling follow-up appointments and addressing medication access issues. Use a secure text-based platform to engage patients, respond to needs, and escalate care concerns to the appropriate clinical team member. Monitor hospital admission and discharge reports and proactively reach out to enrolled patients. Support patients with navigation of health systems, including insurance questions and provider access. Participate in daily team huddles, report progress, and track patient engagement and task completion. Document all activities in EHR/Phamily platform in real-time according to compliance standards. Escalate critical needs to licensed social workers, nurses, or physicians based on escalation guidelines. Support quality goals such as reducing readmissions, improving care coordination, and closing SDOH gaps.
Key Skills & Qualifications
Required: Active LPN or CMA/RMA certification in good standing Preferred: Experience in social work, case management, hospital navigation, or transitional care coordination 2+ years of experience in clinical, community health, or post-acute care settings Comfortable using text-based health platforms, EMRs, and digital communication tools Strong knowledge of community resources, health equity, and SDOH Critical thinking skills and ability to triage needs with urgency and empathy Excellent written communication and time management Bilingual (Spanish/English) a plus but not required
Schedule & Work Environment
Full-time, Monday–Friday Flexible remote schedule across CST, EST, or PST time zones 1-hour lunch break, daily huddles with manager/team Ongoing support from a multidisciplinary care team
Why Join Us?
Be a part of a mission-driven organization focused on health equity and innovative digital care Collaborative, diverse, and growth-focused culture Opportunities for professional development and internal promotion Competitive compensation and benefits package Professional development support Be part of redefining how care is delivered—one text at a time
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Other Industries Hospitals and Health Care Referrals increase your chances of interviewing at Phamily by 2x Get notified about new Care Coordinator jobs in
Washington, United States . Washington, United States $90,000.00-$95,000.00 1 month ago Clinical Care Coordinator (Remote) – Text-Based APCM Program
Program Development Coordinator Multisystemic Therapy
Seattle, WA $55,000.00-$80,000.00 5 months ago Tacoma, WA $55,100.00-$99,000.00 1 week ago Chronic Care Manager (Remote - Compact States)
Tacoma, WA $55,100.00-$99,000.00 1 week ago Washington, United States $34.00-$40.00 9 months ago NON-COMPACT STATE - PT Remote CCM/RTM Care Management Nurse (CA)
Tacoma, WA $55,100.00-$99,000.00 1 week ago Tacoma, WA $55,100.00-$99,000.00 1 week ago Health Home Care Coordinator RN Remote with Field Travel in Tacoma WA
Account Manager, Point of Care and Molecular - Pacific Northwest
Washington Licensed Behavioral Health Care Manager
Seattle, WA $300,000.00-$350,000.00 1 week ago Bellevue, WA $300,000.00-$350,000.00 1 week ago Tacoma, WA $300,000.00-$350,000.00 1 week ago Spokane, WA $300,000.00-$350,000.00 1 week ago We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr