Care Coordinator II, Care Transitions

Avail Health • Rockville, MD

1d • Hybrid

About The Position

Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following hospital discharge. The Care Coordinator II is the operational backbone of the remote interdisciplinary team — executing the coordination tasks that keep NP, RN, and SW Care Manager workflows running smoothly throughout the 30-day TCM episode. This is primarily a work-from-home role. You’ll support virtual care operations through scheduling, documentation, outreach, and referral coordination. On occasion you’ll go into the field to help patients who need hands-on support to participate in telehealth visits. This is a ground-floor opportunity. Early team members will help shape workflows, surface gaps, and build a program designed to scale.

Requirements

• High school diploma or GED required; associate degree or healthcare-related education strongly preferred
• 2+ years of experience in care coordination, home health, health plan care management, patient access, or healthcare operations
• Strong organizational skills with ability to manage concurrent workflows and shifting priorities independently and remotely
• Excellent communication skills with a patient-centered, customer-service-oriented approach
• Comfortable working from home with high accountability and responsiveness across a distributed team
• Comfort navigating multiple technology platforms simultaneously (EMR, scheduling, telehealth, communication tools)
• Valid driver’s license, reliable transportation, and active automobile insurance for field visits
• Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Nice To Haves

• Experience in care management, population health, home health, post-acute care, or transitional care settings
• Experience supporting Medicare, senior, dementia, behavioral health, or medically complex populations
• Background in telehealth, virtual care, or mobile/home-based care delivery
• Strong fit for candidates with combined clinical support and healthcare operations experience — e.g., home health intake staff, transitional care coordinators, or community health workers with practice operations backgrounds

Responsibilities

• Delegated coordination tasks across the NP, RN Care Manager, and SW Care Manager workflows throughout the TCM episode
• Pre-visit prep: records retrieval, referral status, discharge documentation, and scheduling logistics
• Patient and caregiver outreach, appointment reminders, and telehealth readiness support
• Execute delegated tasks from clinical staff: outreach, records retrieval, referral coordination, appointment scheduling, and visit logistics
• Coordinate follow-up appointments, specialist referrals, home services, transportation, and community-based resources
• Conduct patient and caregiver outreach for scheduling, reminders, telehealth preparation, and post-discharge follow-up
• Support patients and caregivers with telehealth onboarding and technology troubleshooting; perform occasional field visits when patients cannot participate independently
• Track outstanding tasks, referral needs, scheduling barriers, and TCM workflow milestones; escalate clinical concerns to licensed staff promptly
• Document coordination activities, outreach attempts, and scheduling updates in the EMR; maintain accurate tracking of referrals and care coordination milestones
• Participate in interdisciplinary huddles and contribute frontline feedback to workflow improvement as the program scales

Benefits

• Medical coverage: DPC model + high-deductible health plan; 100% of employee medical premiums covered
• Dental and vision insurance
• HSA with employer contributions
• Company-paid life and disability insurance
• 401(k) with 2% employer match
• 15 days PTO (accrued per pay period, increasing with tenure)
• 8 + 1 floating holidays
• Mileage reimbursement: $0.725/mile for travel exceeding 30 miles/day (up to $200/day)
• All devices and technology provided

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED