Clinical Services Coordinator, Medical Home Network

Are you ready to join a passionate community of people who are changing how health care is delivered? A place where you will find a career you love while truly making a difference building healthier communities.

The Role

The Clinical Services Coordinator serves as a key member of the clinical operations team, supporting patients, providers, and care teams through patient outreach, care coordination, scheduling, preventive care initiatives, and transitional care activities. This role is responsible for engaging patients across multiple population health programs, including Annual Wellness Visits (AWVs), Timely Follow-Up/Transitions of Care (TOC), preventive screenings, and other value-based care initiatives. Additionally, this role supports critical agentic AI work alongside tech and product teams.

The Clinical Services Coordinator partners closely with interdisciplinary care teams to improve patient access, coordinate services, close care gaps, and ensure timely follow-up. This position leverages technology-enabled tools, AI, electronic medical records, and population health reports to identify outreach opportunities, support quality initiatives, and enhance the patient experience.

The Perks

• 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.
• Great work-life benefits: Paid time off, sick time, and 12 paid holidays.
• Fully Remote Schedule

What You Can Look Forward To

Patient Outreach, Scheduling & Care Coordination

• Conduct proactive patient outreach to support 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 while addressing barriers to care and improving appointment adherence.
• Coordinate services across primary care, specialty care, behavioral health, and community-based organizations.
• Build collaborative relationships with patients, caregivers, providers, and community partners to improve care access and patient outcomes.
• Provide patient education, reinforce care plans, and support self-management activities.
• Assist patients in navigating healthcare services, insurance resources, transportation, and other community supports.

Population Health & Preventive Care

• Utilize EMR, population health registries, Agentic AI tools, and reporting platforms to identify patients due for preventive services, follow-up appointments, and quality interventions.
• Support Annual Wellness Visit workflows, preventive care initiatives, quality measure performance, and value-based care programs.
• Assist with standardized screenings and assessments, including health risk assessment, PHQ-9s, and social determinants of health (SDOH) screening, as appropriate.
• Monitor assigned patient work queues and outreach lists to ensure timely completion of clinical and operational priorities.
• Collaborate with Care Transformation Partners to support health centers’ needs and participate in finding solutions to current challenges or barriers.

Timely Follow-Up & Transitions of Care

• Conduct timely outreach following emergency department visits, hospital admissions, and other care transitions to support continuity of care.
• Coordinate post-discharge appointments, medication reconciliation or review, referrals, and additional follow-up activities as directed.
• Identify and escalate clinical, behavioral health, or social concerns to licensed clinicians or appropriate members of the care team.

Clinical Operations & Quality Improvement

• Collaborate with providers and interdisciplinary teams to improve patient engagement, reduce care gaps, and achieve quality and population health goals.
• Participate in quality improvement initiatives, workflow optimization, and implementation of new clinical programs.
• Support standardized workflows and best practices across clinical service lines.
• Assist with onboarding, training, and sharing best practices with team members as needed.
• Contribute to optimizing and documenting workflows to establish standards of care, best practices, and policies.

Documentation, Compliance & Technology

• Maintain accurate, timely, and complete documentation within the EMR and care management platforms.
• Ensure compliance with organizational policies, regulatory requirements, privacy standards, and documentation guidelines.
• Utilize technology-enabled outreach platforms, AI-assisted patient engagement tools, and other digital solutions to enhance workflow efficiency and patient engagement.
• Monitor outreach activities and documentation to support performance reporting and quality metrics.

What You’ll Need to Succeed

• 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 one or more of the following settings: 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 in 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 is desirable.