Description:
About the Role:
At Ensemble CIN in Albuquerque, we believe healthcare works best when it meets people where they are. As a Care Coordinator II, you’ll be part of a small, mission-driven team helping patients with complex needs stay healthy. You’ll build real relationships, coordinate meaningful care, and make a tangible difference—every single day.
Key Responsibilities:
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On site work at Gateway West with Unhoused Senior population/Shelter
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Carry Caseload
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Perform Intakes
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Identify Resource Needs and Assist with Obtaining – housing, transportation, food, clothing, health insurance applications, cell phones, PCP/Specialist Care, etc.
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Goal of Rehousing Seniors
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Work in the Community to network with vendors who can help with resource needs
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Work in the Community to follow up on Seniors rehoused
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Timely and accurate documentation of hours applied to shelter work and EMR documentation
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Manage ongoing care coordination for chronically ill or high-risk patients
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Collaborate with physicians, nurses, and partner providers to develop and monitor care plans
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Track patient outcomes and follow up regularly to ensure goals are met
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Navigate care transitions across hospitals, clinics, and home-based settings
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Advocate for patient needs with empathy, clarity, and persistence
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Document assessments, care activities, and progress in EMR systems
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Participate in interdisciplinary team meetings and case conferences
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Support culturally responsive care and build trust with diverse communities
Requirements:
What We’re Looking For:
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2+ years of care coordination, case management, or similar experience
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Bilingual in Spanish and English — able to connect with families in both languages
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Deep understanding of community-based care models
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Strong organizational skills and the ability to juggle multiple priorities
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Compassionate communicator who knows how to listen and lead
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Comfortable using EMR tools and documenting care accurately
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Able to work independently while staying deeply connected to the team
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Passion for meaningful, equity-driven work in a value-based care setting
Why Join Us:
Ensemble CIN is part of a pioneering movement to reshape healthcare through connection, collaboration, and courage. Backed by CareM Management Services, we serve as the clinical backbone for high-need populations in New Mexico. We offer a supportive team environment, opportunities to grow, and the chance to be part of something truly meaningful.
Our mission is simple but powerful: to bring out the courage in others — whether that’s a patient facing a new diagnosis or a teammate finding their voice. If that speaks to you, we hope you’ll apply.
