Provide remote telehealth advocacy and care coordination for older adults with complex medical and social needs, helping them navigate chronic conditions, insurance barriers, referrals, and gaps in care. Work closely with physicians to build individualized care plans and support patients with health literacy, self-management, and connection to community resources. The role emphasizes long-term relationship building, persistent problem-solving, and use of new digital tools and EHR workflows.
Key Responsibilities
- Guide patients through medical and insurance complexity using clear, plain language.
- Coordinate care across providers, specialists, clinics, and insurers.
- Build individualized care plans with physicians that address medical needs and social determinants of health.
- Help patients secure transportation, food assistance, mobility support, and access to primary care.
- Identify and work through barriers such as denied claims, missed referrals, medication affordability, and care gaps.
- Coach patients on health literacy and self-management for chronic conditions, including diabetes, chronic pain, mobility, and medication adherence.
- Lead difficult conversations with empathy, firm boundaries, and persistence.
- Use EHR and AI-enabled tools while sharing frontline feedback to improve workflows and advocacy processes.
Required
- Active Compact RN license or California RN license in good standing.
- Current U.S. residency/based in the United States.
- Experience working with diverse, vulnerable patient populations.
- Strong interpersonal, active listening, and communication skills.
- Strong organization and administrative skills.
- Comfort learning a new EHR and adopting AI tools.
Preferred
- Background in community health or health coaching.
- Experience working with Medicare populations.
- Fluency in Spanish or other languages.
Benefits & Perks
- Fully remote work with video and phone-based care.
- 1099 contract arrangement.
- Long-term commitment and continuity with patients.
- Opportunity to work with physicians in an advocacy-first telehealth model.
- Use of evolving AI tools and operational processes.