Care Concierge, US Remote

About CarewellCarewell is a category-defining business dedicated to providing trusted caregiving solutions and support for individuals and families. Through Carewell Family Services, we extend our commitment beyond products to person-centered navigation, care coordination, and advocacy services that address both medical and social needs. Our approach emphasizes compliance, scalability, and high-quality patient experiences while working in close partnership with clinicians and community resources to support better outcomes.About The RoleThis is an opportunity to join a growing care navigation program at a moment when your contribution will directly shape how it scales. As a Care Concierge, you are the steady presence in a patient's healthcare journey — the person who keeps all the moving pieces connected, translates what matters, and makes sure nothing falls through the cracks.You will support older adults managing serious, high-risk chronic conditions — heart failure, COPD, diabetes, dementia, cancer — through proactive care coordination, education, and advocacy. This is remote work with deep human connection: you will build trust with patients over time, help them navigate a complex healthcare system, address barriers to care, and partner with clinical teams to support better health outcomes.The right person brings healthcare experience, genuine empathy for vulnerable populations, and the self-direction to manage a caseload independently. You understand that meaningful care navigation isn't measured by task completion — it's measured by a patient who feels supported, understands their options, and can access the care they need.This is a full-time, remote, W2 role hiring in the following states: Florida, Georgia, North Carolina, Tennessee, TexasWhat You'll DoPatient Engagement & Relationship BuildingServe as the primary point of contact for enrolled patients, building trust and rapport over time through consistent, compassionate outreachConduct regular check-ins with patients to assess their health status, care needs, and social barriers — meeting them where they are emotionally and practicallyMaintain a caseload of approximately 150 patients, prioritizing outreach based on clinical acuity, recent transitions, and care gapsBuild relationships with patients' family members and caregivers when appropriate to support coordinated careCare Navigation & CoordinationNavigate patients through the healthcare system — coordinating appointments, facilitating communication between providers, and ensuring care plans are understood and actionableServe as a liaison between patients, primary care providers, specialists, pharmacies, home health agencies, and community resourcesSupport medication adherence by identifying barriers, educating on proper use, and escalating discrepancies or concerns to clinical staffHelp patients access durable medical equipment, transportation services, meal programs, and other community-based resources that support their health and independenceEscalate clinical concerns — new symptoms, worsening conditions, or urgent needs — to the supervising LVN or clinical team promptly and clearlySocial Determinants of Health (SDOH) Screening & Resource ConnectionConduct structured SDOH screenings using validated tools to identify barriers such as food insecurity, housing instability, transportation challenges, and financial strainConnect patients with appropriate community resources, benefits programs, and social services to address identified needsFollow up to confirm patients were able to access resources and troubleshoot barriers when connections failBuild and maintain a regional resource directory, updating it as programs and eligibility requirements changePatient Education & Self-Management SupportProvide condition-specific education tailored to the patient's literacy level, language, and learning preferences — reinforcing what their clinical team has taught themCoach patients on self-management strategies: symptom monitoring, when to call the doctor, medication routines, diet modifications, and activity goalsUse motivational interviewing techniques to support behavior change and goal-setting in partnership with the patientDeliver culturally sensitive, trauma-informed care that respects patients' beliefs, preferences, and lived experiencesPost-Hospital & Emergency Department Follow-UpConduct timely follow-up calls within 24-72 hours of hospital discharge or ED visit to support safe transitions homeReview discharge instructions with patients in plain language, ensuring they understand medications, follow-up appointments, and warning signsConfirm that follow-up appointments are scheduled and that the patient has transportation; reschedule or arrange rides when neededReconcile patient-reported medications with discharge records and escalate any discrepancies to clinical staff immediatelyDocumentation & ComplianceDocument all patient interactions accurately and completely in real time, including time spent, interventions delivered, barriers identified, and outcomes achievedTrack navigation time per patient per month to support accurate billing under CMS Principal Illness Navigation (PIN) codesMaintain compliance with CMS billing requirements, HIPAA privacy standards, and program protocolsRespond constructively to quality audits, chart reviews, and performance feedbackKPI's You'll DriveCaseload engagement rate — Consistent outreach to all assigned patients within established cadenceCare gap closure — Identified gaps resolved or actively in progress each monthAppointment adherence support — Follow-up appointments confirmed and transportation arranged for patients post-transitionResource connection rate — Patients with identified SDOH needs successfully connected to community resources or benefit programsDocumentation compliance — All patient interactions documented in real time with no incomplete or late encounter notesEscalation response time — Concerns escalated to supervising LVN same day they are identifiedPatient satisfaction — Positive experience reflected through periodic program feedback and check-in surveys30-day readmission support — Proactive monitoring and outreach for high-risk patients post-discharge, contributing to reduction in avoidable readmissionsProductivity — Caseload managed with consistent daily and weekly output across outreach attempts, follow-ups, and documentation — volume and quality of activity are both accounted forRequiredWho You AreAuthorized to work in the US without employee sponsorshipLocated in Florida, Georgia, North Carolina, Tennessee, or TexasIf located in Texas, must hold a current, active CHW certificationActive Certified Medical Assistant (CMA) or Registered Medical Assistant (RMA) credential1+ years of patient-facing healthcare experience in any of the following settings: medical front office, ambulatory care, primary care, senior care, case management, patient coordination, utilization management, or value-based care programsDemonstrated ability to build trust and communicate effectively with older adults and individuals managing serious chronic conditionsStrong understanding of care coordination principles — you know how healthcare systems work and where patients get stuckComfortable discussing chronic conditions, medications, and treatment plans with patients — you can reinforce clinical guidance without providing medical adviceProficient with EHR systems, care management platforms, and digital communication tools — you can navigate multiple systems simultaneously during patient callsSelf-directed and metric-aware — you manage your own time, track your caseload proactively, and own follow-through without being micromanagedComfortable with ambiguity and rapid iteration — you thrive in environments where processes are still being built and your input mattersHigh school diploma or equivalent required; associate's or bachelor's degree in healthcare, social work, public health, or related field strongly preferredProven remote work capability — reliable internet, professional home workspace, ability to maintain productivity and presence without in-office oversightNice to HaveCommunity Health Worker (CHW) certification or trainingExperience working with Medicare-enrolled or dual-eligible populationsFamiliarity with value-based care models, Accountable Care Organizations (ACOs), or Medicare Advantage programsExperience conducting post-hospital or post-ED transitional care callsPrior experience with SDOH screening tools or community resource navigationBilingual (Spanish strongly preferred; other languages depending on target population)Experience with EHR platforms commonly used in care management (Epic, Cerner, Allscripts, etc.)Why This RoleGround-floor opportunity to help build a program from day one — your work will directly shape how we grow and what best practices we establishClose partnership with clinical leadership and program operations — your observations and insights will inform how we scaleMeaningful, mission-driven work with visible impact — you will see the direct results of your efforts in patients' livesCompetitive compensation with growth trajectory tied to program expansion and demonstrated performanceAccess to comprehensive training on CMS Principal Illness Navigation (PIN) services, care coordination best practices, and condition-specific educationSupportive pod-based structure with LVN clinical supervision and peer collaborationWhat We OfferCompetitive compensation Health, Dental, and Vision insuranceShort-term Disability and Life Insurance (100% employer-sponsored)Long-term DisabilitySupplemental Life Insurance (employee-sponsored)401(k) Retirement Plan100% Remote / No Travel Required6 Paid HolidaysPTO: 10-15 days per year based on tenure milestones