Ambulatory Care Coordinator, Chronic Disease Management

Job Description

Location: Dallas, TX (Onsite)

We are hiring for a Ambulatory Care Coordinator, Chronic Disease Management with a population health management organization located in Dallas, TX. This position is a full-time, direct hire opportunity.

This is a high-impact patient-facing role for someone who is passionate about preventing hospitalizations and helping chronically ill patients live healthier, more independent lives. You will be a consistent point of contact for patients managing conditions like diabetes, heart failure, COPD, and hypertension.

Responsibilities:

• Outreach to patients with chronic conditions to assess care needs and barriers.
• Facilitate scheduling and completion of preventive care visits, lab work, and specialist appointments.
• Review care gap reports and contact patients to coordinate needed HEDIS or quality measure services.
• Promote medication adherence through patient education, refill reminders, and pharmacy coordination.
• Connect patients with community resources for transportation, food assistance, and social services.
• Document patient interactions, care coordination activities, and follow-up tasks in EHR systems.
• Collaborate with care team to develop individualized care plans for complex patients.
• Facilitate warm handoffs between hospital discharge, specialist referrals, and home health services.
• Enroll eligible patients in disease management, wellness programs, and value-based care initiatives.

Qualifications:

• Associate degree in health sciences, medical assisting, or a related field; bachelor’s degree preferred
• Minimum 2 years of experience in patient care coordination, community health, or a clinical support role
• Familiarity with chronic disease conditions including diabetes, hypertension, heart failure, and COPD
• Experience with EHR systems and care management platforms
• Knowledge of HEDIS quality measures and value-based care program requirements preferred
• Strong interpersonal skills with ability to build trust with diverse, chronically ill patient populations

Schedule:

• Full-time position
• Standard business hours, M-F
• Standard full-time hours per pay period

Salary Range: The salary range for this position is approximately $42,000 – $58,000 annually ($20.19 – $27.88 per hour), based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.