Care Concierge, US Remote

About Carewell

Carewell 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 Role

This 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.

What You'll Do

Patient Engagement & Relationship Building

• Serve as the primary point of contact for enrolled patients, building trust and rapport over time through consistent, compassionate outreach
• Conduct regular check-ins with patients to assess their health status, care needs, and social barriers — meeting them where they are emotionally and practically
• Maintain a caseload of approximately 150 patients, prioritizing outreach based on clinical acuity, recent transitions, and care gaps
• Build relationships with patients' family members and caregivers when appropriate to support coordinated care
• Conduct the initial welcome visit ahead of the initiating MD visit — introduce the program, explain its value, and in some cases secure patient consent to enroll. Comfortable guiding hesitant patients toward a "yes" through a trust-based, persuasive conversation.

Care Navigation & Coordination

• Navigate patients through the healthcare system — coordinating appointments, facilitating communication between providers, and ensuring care plans are understood and actionable
• Serve as a liaison between patients, primary care providers, specialists, pharmacies, home health agencies, and community resources
• Support medication adherence by identifying barriers, educating on proper use, and escalating discrepancies or concerns to clinical staff
• Help patients access durable medical equipment, transportation services, meal programs, and other community-based resources that support their health and independence
• Escalate clinical concerns — new symptoms, worsening conditions, or urgent needs — to the supervising LVN or clinical team promptly and clearly

Social Determinants of Health (SDOH) Screening & Resource Connection

• Conduct structured SDOH screenings using validated tools to identify barriers such as food insecurity, housing instability, transportation challenges, and financial strain
• Connect patients with appropriate community resources, benefits programs, and social services to address identified needs
• Follow up to confirm patients were able to access resources and troubleshoot barriers when connections fail
• Build and maintain a regional resource directory, updating it as programs and eligibility requirements change

Patient Education & Self-Management Support

• Provide condition-specific education tailored to the patient's literacy level, language, and learning preferences — reinforcing what their clinical team has taught them
• Coach patients on self-management strategies: symptom monitoring, when to call the doctor, medication routines, diet modifications, and activity goals
• Use motivational interviewing techniques to support behavior change and goal-setting in partnership with the patient
• Deliver culturally sensitive, trauma-informed care that respects patients' beliefs, preferences, and lived experiences

Post-Hospital & Emergency Department Follow-Up

• Conduct timely follow-up calls within 24-72 hours of hospital discharge or ED visit to support safe transitions home
• Review discharge instructions with patients in plain language, ensuring they understand medications, follow-up appointments, and warning signs
• Confirm that follow-up appointments are scheduled and that the patient has transportation; reschedule or arrange rides when needed
• Reconcile patient-reported medications with discharge records and escalate any discrepancies to clinical staff immediately

Documentation & Compliance

• Document all patient interactions accurately and completely in real time, including time spent, interventions delivered, barriers identified, and outcomes achieved
• Track navigation time per patient per month to support accurate billing under CMS Principal Illness Navigation (PIN) codes
• Maintain compliance with CMS billing requirements, HIPAA privacy standards, and program protocols
• Respond constructively to quality audits, chart reviews, and performance feedback

KPI’s You’ll Drive

• Caseload engagement rate — Consistent outreach to all assigned patients within established cadence
• Enrollment conversion — Patients successfully consented and enrolled following the Welcome Visit
• Care gap closure — Identified gaps resolved or actively in progress each month
• Appointment adherence support — Follow-up appointments confirmed and transportation arranged for patients post-transition
• Resource connection rate — Patients with identified SDOH needs successfully connected to community resources or benefit programs
• Documentation compliance — All patient interactions documented in real time with no incomplete or late encounter notes
• Escalation response time — Concerns escalated to supervising LVN same day they are identified
• Patient satisfaction — Positive experience reflected through periodic program feedback and check-in surveys
• 30-day readmission support — Proactive monitoring and outreach for high-risk patients post-discharge, contributing to reduction in avoidable readmissions
• Productivity — Caseload managed with consistent daily and weekly output across outreach attempts, follow-ups, and documentation — volume and quality of activity are both accounted for

Who You Are

Required

• Availability to work Monday - Friday 9am - 6pm EST with no restrictions
• Must be located in: FL, GA, NC, TN, or TX
• Must have an active Certified Medical Assistant (CMA) or Registered Medical Assistant (RMA) credential from a nationally recognized certifying organization.
• 1+ 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 programs
• Persuasive and patient-centered communicator — comfortable introducing a new program, addressing hesitation, and guiding undecided patients toward enrollment through a trust-based conversation.
• Demonstrated ability to build trust and communicate effectively with older adults and individuals managing serious chronic conditions
• Strong understanding of care coordination principles — you know how healthcare systems work and where patients get stuck
• Comfortable discussing chronic conditions, medications, and treatment plans with patients — you can reinforce clinical guidance without providing medical advice
• Proficient with EHR systems, care management platforms, and digital communication tools — you can navigate multiple systems simultaneously during patient calls
• Self-directed and metric-aware — you manage your own time, track your caseload proactively, and own follow-through without being micromanaged
• Comfortable with ambiguity and rapid iteration — you thrive in environments where processes are still being built and your input matters
• High school diploma or equivalent required; associate's or bachelor's degree in healthcare, social work, public health, or related field strongly preferred
• Proven remote work capability — reliable internet, professional home workspace, ability to maintain productivity and presence without in-office oversight

Nice to Have

• Community Health Worker (CHW) certification or training
• Experience working with Medicare-enrolled or dual-eligible populations
• Familiarity with value-based care models, Accountable Care Organizations (ACOs), or Medicare Advantage programs
• Experience conducting post-hospital or post-ED transitional care calls
• Prior experience with SDOH screening tools or community resource navigation
• Bilingual (Spanish strongly preferred; other languages depending on target population)
• Experience with EHR platforms commonly used in care management (Epic, Cerner, Allscripts, etc.)

Why This Role

• Ground-floor opportunity to help build a program from day one — your work will directly shape how we grow and what best practices we establish
• Close partnership with clinical leadership and program operations — your observations and insights will inform how we scale
• Meaningful, mission-driven work with visible impact — you will see the direct results of your efforts in patients' lives
• Competitive compensation with growth trajectory tied to program expansion and demonstrated performance
• Access to comprehensive training on CMS Principal Illness Navigation (PIN) services, care coordination best practices, and condition-specific education
• Supportive pod-based structure with LVN clinical supervision and peer collaboration

What We Offer

• Competitive compensation 
• Health, Dental, and Vision insurance
• Short-term Disability and Life Insurance (100% employer-sponsored)
• Long-term Disability
• Supplemental Life Insurance (employee-sponsored)
• 401(k) Retirement Plan
• 100% Remote / No Travel Required
• 6 Paid Holidays
• PTO: 10-15 days per year based on tenure milestones