[Hiring] Clinical Care Coordinator @Winning Assistants

Role Description

Our Client is looking for a highly skilled Remote Clinical Care Coordinator (RN) to support referral intake, clinical review, discharge coordination, and proactive patient follow-up within a home health environment. This role functions as a clinical liaison and operational lead for referral intake, eligibility determination, risk stratification, and care coordination, helping ensure patients receive safe and appropriate care while reducing avoidable hospital readmissions. The ideal candidate is a confident clinical professional who can assess patient needs, identify potential complications, and coordinate effectively with physicians, hospitals, clinicians, and patients.

Key Responsibilities

• Referral Intake & Clinical Review
  • Receive, log, and triage referrals from hospitals, skilled nursing facilities (SNFs), physicians, and community partners.
  • Review clinical documentation such as H&P, discharge summaries, therapy notes, progress notes, and physician orders to ensure accuracy and completeness.
  • Communicate with referral sources to obtain missing documentation or clarify clinical needs.
  • Determine whether patients are appropriate for home health services based on clinical risk and operational capacity.
• Eligibility Screening for Home Health Services
  • Screen referrals to ensure patients meet home health eligibility requirements, including homebound status, skilled nursing or therapy needs, and physician oversight with valid orders.
  • Verify insurance coverage such as Medicare, Medicare Advantage, Medicaid, and commercial plans.
  • Confirm service area coverage and staffing availability before patient acceptance.
• Clinical Risk Stratification & Acuity Assessment
  • Assess the risk of hospital readmission and identify high-risk patients based on factors such as recent hospitalizations or SNF stays, multiple or unstable comorbidities, polypharmacy or complex medication regimens, and limited caregiver support or other social risk factors.
  • Escalate high-risk cases to clinical leadership when necessary.
• Identification of Clinical Complications
  • Screen referrals for high-acuity needs such as complex wounds or infection risks, IV therapy including PICC or central line care, enteral feeding tubes (NG, G-tube, or J-tube), catheter or ostomy management, and respiratory support such as oxygen therapy, tracheostomy, or ventilator care.
  • Ensure patient acuity aligns with available nursing competencies.
• Care Coordination & Collaboration
  • Coordinate with the Clinical Manager and care teams regarding care coordination meetings, high-risk patient discussions, and the escalation of clinical concerns.
  • Provide clear clinical handoffs to field nurses, schedulers, and care teams.
• Hospital & Referral Partner Communication
  • Serve as a primary clinical contact for hospitals and skilled nursing facilities.
  • Send reports and updates regarding admissions, care delays, and discharge planning when required.
  • Maintain accurate reporting records and documentation.
• Patient Tuck-In Calls & Readmission Prevention
  • Conduct weekly tuck-in calls every Thursday and Friday to check patient status before the weekend.
  • Identify red flags such as symptom changes, medication issues, wound concerns, or caregiver challenges.
  • Escalate concerns that may require weekend nursing visits, therapy intervention, physician communication, or care plan adjustments.
  • Document findings to support proactive readmission prevention.

Qualifications

• Registered Nurse (RN) or strong clinical background required.
• Relevant medical degree or nursing education required.
• Active nursing license preferred.
• Experience in home care or home health is strongly preferred.
• Strong clinical judgment for referral review, patient triage, and discharge planning.
• Ability to assess patient symptoms and identify potential complications independently.
• Detail-oriented when reviewing referrals, documentation, and care plans.
• Confident decision-maker who can escalate concerns appropriately.
• Ability to reduce readmission risk through proactive follow-up and care coordination.
• Reliable with a long-term mindset and strong sense of accountability.

Requirements

• Must be proficient in speaking and writing English very clearly.
• Excellent phone communication skills with patients, families, clinicians, and physicians.
• Professional, calm, and reassuring bedside manner when communicating with patients.
• Comfortable coordinating with multiple stakeholders including doctors, hospitals, and internal teams.

Technical Requirements

• Device: Reliable laptop or desktop computer.
• Internet: High-speed connection (minimum 10 Mbps).
• Audio: Noise-canceling headset.
• Video: Webcam for virtual meetings.
• Workspace: Quiet, professional environment.

Benefits

• Dedicated HR & Contractor Support Team: Access to world-class support for questions, guidance, contract matters, and client communication.
• Premium VPN Access (Optional): A secure VPN license can be provided upon request to enhance privacy and security for client-related tasks.
• HIPAA & Cybersecurity Training + Certification (Provided): Access to our internal HIPAA compliance training, cybersecurity modules, and certification to help you confidently handle PHI for U.S. healthcare clients.
• Top 1% VA Performance Training: Access to our proprietary training on communication, client management, productivity systems, and best practices to help you become a top-performing VA and increase long-term client retention.
• Client-Approved U.S. Holidays: Contractors may take U.S. holidays off according to the client’s needs and schedule.
• Client-Approved Paid or Unpaid Time Off: Time off may be granted by your client. Paid time off is optional and only if offered by the client.
• Access to Tools & Resources: Templates, workflow guides, productivity tools, and client-specific SOP support to help you perform at your best.
• Optional Performance-Based Incentives: Some clients may offer bonuses, incentives, or increased hours based on your performance.