Clinical Agent (TCM / CCM / RPM)

Job Type: Full-Time
Location: Remote (United States)

About the Role

Adnab Research Inc. is looking for a compassionate, organized Clinical Agent to support patients across multiple care management programs. This role combines patient outreach, care coordination, enrollment, and clinical triage to help patients receive the care they need after hospitalization and while managing chronic conditions.

You will work across:

• Transitional Care Management (TCM) – Supporting patients after hospital discharge
• Chronic Care Management (CCM) – Monthly care coordination for patients with chronic conditions
• Remote Patient Monitoring (RPM) – Patient enrollment, onboarding, and incident triage

Using multiple Electronic Medical Records (EMRs) alongside Adnab Research Inc's proprietary care management platform, you will coordinate patient care, document clinical interactions, and manage patient workflows across numerous healthcare organizations. Success in this role requires someone who is comfortable learning new technology, adapting to multiple EMRs and proprietary software platforms, and navigating different client workflows. This position serves as one of the primary points of contact for patients, helping remove barriers to care, coordinating appointments, identifying social needs, and ensuring every patient feels supported throughout their healthcare journey.

Remote Patient Monitoring (RPM) – Clinical Triage

• Review out-of-range vital sign alerts (blood pressure, glucose, weight, oxygen saturation, etc.).
• Contact patients to assess symptoms and clinical status.
• Evaluate medication adherence and contributing factors.
• Follow established clinical protocols to determine appropriate next steps.
• Escalate urgent concerns to providers when necessary.
• Educate patients on disease management and proper device use.
• Document all assessments, interventions, and patient communications within the EMR and Caret Health platform.

Transitional Care Management (TCM)

• Review newly discharged patients assigned for outreach.
• Contact patients within required compliance timeframes.
• Complete structured post-discharge assessments, including:
• Symptom review
• Medication reconciliation support
• Transportation assessment
• Social Determinants of Health (SDOH) screening
• Schedule or confirm required primary care follow-up appointments.
• Coordinate with providers and care teams to ensure successful care transitions.

Chronic Care Management (CCM)

• Conduct monthly outreach calls to enrolled patients.
• Review and update individualized care plans.
• Provide chronic disease education tailored to each patient's diagnoses and goals.
• Accurately document monthly care management time for CMS and payer compliance.

Shared Responsibilities

• Utilize multiple EMRs and Adnab Research Inc's proprietary care management technology to manage patient workflows, document encounters, and track program progress.
• Identify barriers to care, including transportation, financial, and social needs, and connect patients with appropriate resources.
• Escalate clinical concerns or significant changes in patient status to Clinical Leads.
• Maintain accurate documentation within the care management platform and client EMRs.
• Follow all established workflows, quality standards, and client-specific protocols.
• Manage a caseload spanning multiple hospitals and health systems.
• Adapt outreach and documentation to each client's specific requirements.
• Communicate effectively with teammates through Slack and other internal communication platforms.
• Maintain HIPAA compliance in all patient interactions, documentation, and data handling.
• Document outreach attempts, assessments, enrollments, and program milestones accurately to support compliance and billing requirements.

Qualifications Required

• 1+ years of experience in healthcare outreach, care coordination, patient services, medical assisting, or a similar healthcare role.
• Excellent verbal communication and patient engagement skills.
• Ability to build rapport with patients from diverse backgrounds.
• Ability to manage multiple priorities and caseloads simultaneously.
• Strong organizational, time management, and documentation skills.
• Comfortable learning new technology and quickly adapting to multiple Electronic Medical Records (EMRs), proprietary software platforms, and client-specific workflows.
• Strong computer skills with the ability to efficiently navigate multiple systems simultaneously.
• Ability to work independently in a remote environment while maintaining productivity and accountability.
• HIPAA-compliant home workspace.

Preferred

• Medical Assistant, Community Health Worker, Care Coordinator, or similar clinical background.
• Experience with:
• Remote Patient Monitoring (RPM)
• Chronic Care Management (CCM)
• Transitional Care Management (TCM)
• Telehealth or Durable Medical Equipment (DME) programs
• Experience educating patients with chronic conditions such as:
• Diabetes
• Hypertension
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Familiarity with:
• Electronic Medical Records (Epic, Cerner, TruBridge, Athena, eClinicalWorks, or similar)
• Trello
• Aircall
• Slack
• Bitwarden
• Bilingual (Spanish or other languages relevant to the patient population) preferred.

Pay: $21.00 - $23.00 per hour

Work Location: Remote