High Risk Care Coordinator

Who You Are You are a Licensed Practical N urse (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. Who We Are 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. With Oasis, patients receive better access and care. Providers receive the data, resources and expertise to be successful in value-based care arrangements. Pa yors get the benefit of a solution that improves performance, drives growth and reduces the total cost of care in hard-to-engage markets. Together, we will boldly advance primary care for those that need it most. We are excited for you to join us on this journey. We invite you to be a part of Oasis, where you’ll discover we listen first, do the right thing, build things together and go all in --- while having fun! Your Role 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, and 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 Leader