Care Coordinator, Embedded (Atlanta, GA - Sandy Springs)

About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.” Join Ennoble Care today!

Ennoble Care is seeking a full-time Care Coordinator, Embedded to join our team, providing on-site support within one or more partnered long-term care facilities in the Atlanta, Georgia area, with a primary focus on the Sandy Springs region. This role is an integral, in-person member of our clinical care team, working alongside Ennoble Care providers in a family-practice-style model of care that emphasizes continuity, relationship-building, and patient-centered support.

At Ennoble Care, we foster a positive, respectful culture rooted in teamwork, where individuals are valued and encouraged to do meaningful work while maintaining a healthy work-life balance. We support internal advancement and long-term career growth based on performance, organizational needs, and role availability.

KEY ROLE RESPONSIBILITIES

• Facility Presence & Engagement
  • Maintain a consistent, reliable daily presence within assigned facilities, serving as an embedded member of the care team
  • Engage proactively and regularly with residents to support care plans, follow-ups, and care transitions
  • Serve as a trusted liaison between providers, facility staff, residents, and families, helping ensure clear communication and continuity of care
  • Act as a vital communication bridge between facility staff, Ennoble Care providers, and hospice teams
  • Contribute to strong facility partnerships and collaborative team dynamics that support high-quality, patient-centered care

• Clinical Communication & Care Coordination
  • Provide timely, accurate clinical updates to Ennoble Care providers to support informed, coordinated decision-making
  • Communicate patient needs, changes in condition, and urgent concerns clearly and promptly to the clinical team
  • Support care coordination efforts that promote continuity of care and help prevent unnecessary hospitalizations
  • Accurately document patient interactions and care coordination activities in alignment with established workflows and standards
  • Follow documentation and escalation protocols to support safe, efficient, and effective clinical operations

• Vital Signs & Symptom Monitoring
  • Support routine and urgent vital sign collection to help ensure timely clinical insight and patient safety
  • Monitor patients experiencing acute symptoms and escalate care appropriately in coordination with the clinical team, as needed (CCM billable)

• Remote Patient Monitoring (RPM) & Chronic Care Management (CCM)
  • Facilitate enrollment in Remote Patient Monitoring (RPM) for eligible facility-based patients to support ongoing, data-informed care
  • Monitor and support patients to achieve the required 16 readings per month, helping ensure program effectiveness and continuity of care
  • Identify and engage appropriate patients for Chronic Care Management (CCM) services, ensuring accurate documentation and billing compliance

• Telehealth Facilitation
  • Coordinate and support urgent telehealth visits for facility-based patients, helping ensure timely access to care and clinical continuity

• New Patient Referrals
  • Facilitate clinical onboarding for new facility-based patients, helping ensure a smooth transition and timely initiation of care
  • Expedite time to first visit by coordinating closely with providers and care teams to support early engagement and continuity of care

• Staff Onboarding & Mentorship
  • Support the onboarding and training of new Embedded Care Coordinators to promote confidence, consiste