Remote Patient Care Coordinator

Axial Patient Care is seeking a compassionate and driven Remote Patient Care Coordinator to oversee and deliver Chronic Care management (CCM) and Remote Patient Monitoring (RPM) services. This position will start as part- time with the opportunity to transition to full-time in the near future. In this remote role, you will work collaboratively with patients to determine their medical needs, develop the best course of action, and oversee their treatment plans, ensuring each client gets high-quality, individualized care. The ideal candidate is compassionate, patient, and knowledgeable about healthcare practices.

Remotely providing basic patient coaching and care to improve patient outcomes Develop a care plan with the patient, family/caregiver(s) and provider Monitor patient outcomes, adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, create goals and monitor progress toward goals and facilitate changes as needed Coaching and educating patients on improving their Chronic Conditions, preventive care and physician directives Telephone outreach to patients Facilitate CCM and RPM program enrollment Concise and accurate documentation Cultivate and support the primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral Coordinate a variety of healthcare programs Review daily measures Oversee a monthly patient roster, ensuring comprehensive care for each individual Aiming for a patient engagement rate of 90% or higher Recruit, train and support care staff as needed