[Hiring] High Risk Care Coordinator @Oasis Health Partners

Role Description You are a Licensed Practical Nurse (LPN) who thrives on connecting with people through compassionate communication. You easily build meaningful relationships and support positive behavior change through partnership rather than pressure. Leveraging your practical nursing knowledge and structured care protocols, you help patients clearly understand and follow their provider-directed care plans. You bring grace under pressure and feel energized by supporting high-risk patients as they work toward improved health and stability. As a High-Risk Care Coordinator, you build trusted, ongoing relationships with high-risk patients through consistent outreach, active listening, and structured clinical support. You regularly engage patients by phone and text to address complex medical and social needs, including:

• Medication management
• Chronic condition monitoring
• Barriers to care

Using patient-centered discussion and established care protocols, you support patients in understanding and adhering to provider-directed care plans while identifying emerging risks that require escalation. This role is part of a new high-risk patient management program being built from the ground up. You will have the opportunity to help shape workflows, outreach strategies, and processes that truly work for patients and care teams. Additional Responsibilities:

• Conduct regularly scheduled outbound outreach to high-risk patients to support ongoing care management, reduce avoidable utilization, and address gaps in care.
• Contribute to the development of a new high-risk patient management program by helping design, test, and refine outreach workflows, documentation practices, and care coordination processes in a growing, non–enterprise EHR environment.
• Perform medication reconciliation and adherence support by reviewing patient-reported medication use, identifying discrepancies, and escalating concerns to the RN or Provider.
• Collect, assess, and document patient-reported symptoms, condition trends, risk indicators, and barriers to adherence within LPN scope of practice.
• Provide disease-specific education, self-management reinforcement, and motivational coaching using approved materials and care pathways.
• Coordinate home health services and durable medical equipment (DME) needs under RN or Provider direction to support patient safety and stability in the home.
• Identify and address social determinants of health impacting high-risk patients, including access to medications, transportation, food, housing support, or financial resources.
• Support coordination and monitoring for patients with complex chronic conditions, including COPD, CHF, diabetes, and hypertension, using established protocols.
• Serve as a consistent point-of-contact for assigned high-risk patient panels, building trusted relationships that promote sustained engagement and accountability.
• Recognize changes in patient status, emerging risks, or non-adherence patterns and escalate promptly through defined clinical pathways.
• Provide feedback to Clinical Operations and Clinical Leadership to support continuous improvement of high-risk patient management programs.

Qualifications

• Completed an accredited practical nursing (LPN) program, with at least two years of prior nursing experience in care coordination, population health, or chronic disease support.
• Licensed as a Licensed Practical Nurse (LPN) and credentialed in good standing in the applicable state(s) of practice.
• Experience making structured, outbound calls, preferably in a call-center environment, and feel confident engaging patients proactively by phone.
• Experience supporting high-risk patients with chronic conditions, care management, or utilization reduction preferred.
• Comfortable performing medication reconciliation, structured symptom monitoring, and care coordination under RN or provider oversight.
• Strong patient communication skills, including the ability to engage, motivate, and support patients using patient-centered techniques.
• Compassionate communicator with strong active listening abilities.
• Highly organized, dependable, and emotionally intelligent, with the ability to manage ongoing patient panels.
• Proficient in EHR documentation and care management or population health tracking tools.
• Able to multitask effectively in a fast-paced outreach environment with strong time management and follow-through skills.

Benefits

• Medical, dental, and vision coverage.
• Generous time off plans.
• Development program that starts with onboarding and continues throughout your career.

Company Description

Oasis Health Partners (Oasis) is building healthier communities by advancing primary care. We partner with patients, providers, and plans to provide personalized, local care for seniors in towns across America. We believe that patients’ needs come first, and that primary care is the foundation of patient-centric healthcare. Together, we will boldly advance primary care for those that need it most. Apply To This Job