Care Coordinator
Handbook

Handbook Index — Detailed Contents

Disclaimer: Care Coordinators work within defined scope; they do not diagnose or prescribe. All care plans are reviewed by licensed supervisors. Version 4.0 · last update 04/2026.

Upfront external cost: $890 (covers state accreditation, malpractice with tail coverage, external compliance fulfillment). Internal credit line of $5,000 available for GoTo Telemed platform expenses. This credit line covers your internal out-of-pocket costs while you ramp up.

Definitions & Abbreviations

RPM: Remote Patient Monitoring · CPT: Current Procedural Terminology · EMR: Electronic Medical Record · SLA: Service Level Agreement · CDC/CMS/TRAN: training authorities.

History of Telehealth

Telehealth originated in the mid-20th century with NASA monitoring astronauts' vitals and rural telephone consultations. In the 1990s, the internet enabled store-and-forward telemedicine. The COVID-19 pandemic accelerated adoption, making virtual care a standard. Today, telehealth is not just about video visits—it's a comprehensive ecosystem of remote monitoring, asynchronous messaging, and care coordination.

From Virtual Visits to Longitudinal Care

Early telehealth focused on one-off urgent visits. The evolution now emphasizes longitudinal care coordination: continuous engagement between visits, medication adherence, lifestyle coaching, and proactive risk management. The Care Coordinator is the linchpin of this model, bridging the gap between infrequent clinician encounters.

Core Telehealth Care Models

• Synchronous: Live video/audio visits.
• Asynchronous: Store-and-forward (e.g., e-consults, messaging).
• Remote Patient Monitoring (RPM): Devices transmit data (BP, glucose) for review.
• Digital-first coordination: The Care Coordinator model, integrating all three.

Reimbursement & Interoperability

Medicare and commercial payers now cover many telehealth coordination services (CPT 99490, 99487, G codes). Interoperability standards (FHIR) allow seamless data exchange between EMRs, labs, and patient apps.

The Future of Telehealth & AI

AI will handle routine data analysis, flagging anomalies, and drafting documentation. This shifts the Care Coordinator's role toward higher-level tasks: complex care navigation, motivational interviewing, and personalized support. AI will trigger more serious involvement — when risk scores rise, the coordinator steps in with a human touch. This partnership will redefine preventive and chronic care.

Care Coordinator Job Description (1099)

• Panel Ownership: Manage a panel of 200–500 patients, building relationships and trust.
• Clinical Support: Conduct check-ins, review symptom trackers, provide education, and reinforce care plans.
• Supervision & Escalation: Work under the direction of supervising physicians/NPs; immediately escalate any red-flag symptoms or deviations.
• Documentation: Maintain accurate, timely notes in the GoTo Telemed EMR using templates and AI assistance.
• Coordination: Facilitate referrals, schedule follow-ups, and ensure closed-loop communication.

Daily Workflow Ownership

You decide your hours within patient needs. The digital home provides a queue of tasks: new messages, AI alerts, overdue follow-ups. You prioritize and execute with autonomy.

Escalation Pathways

Training Pathway and Milestones

All Care Coordinators complete a rigorous, multi-source training curriculum before seeing patients independently.

• CDC-guided public health training: Infection control, health literacy, social determinants.
• CMS billing & compliance: Telehealth coding, documentation requirements, fraud & abuse laws.
• TRAN operational modules: Platform navigation, EMR workflows, secure messaging.
• Internal GoTo Telemed orientation: Culture, protocols, escalation checklists.
• Shadowing & supervised practice: 20+ hours of live shadowing with experienced coordinators.
• Competency validation: Written exam and observed patient interactions.

Ongoing CE: Annual updates and access to a library of specialty-specific resources.

Treatment Protocol Overview

Protocols are developed by our clinical leadership and updated annually. They cover: preventive screenings, hypertension management, diabetes support, post-op checklists, and mental health first aid. Coordinators follow these protocols and use clinical decision support tools within the EMR.

Patient Intake & Check-in Workflow

1. Patient completes digital intake forms (demographics, history, consent).
2. AI reviews responses and flags missing or critical items.
3. Coordinator reviews chart, confirms insurance, schedules initial virtual visit.
4. During check-in, coordinator verifies identity and reason for visit.

Symptom Tracking & Adherence Support

Patients use connected devices or manual logs. The EMR dashboard highlights trends. Coordinators send reminders for medications, labs, and appointments. Non-adherence triggers a protocol-driven outreach (phone call, message).

Note Writing Standards & Templates

Use standardized templates (SOAP note format) with smart phrases. AI can pre-populate objective data from RPM. Always add subjective assessment and plan. Notes must be completed within 24 hours.

$890 upfront external This covers state-specific accreditation, malpractice insurance with tail coverage, and external compliance verification. GoTo Telemed provides a $5,000 internal credit line to cover platform fees, training materials, and other internal expenses — you are not out-of-pocket for those.

Self-Operatable Credentialing Workflow

1. Complete your CAQH profile (we provide guidance).
2. Submit applications to contracted payers via our portal.
3. Track status in the credentialing dashboard.
4. Hospital enrollment (if required) follows a parallel process.

All compliance documents are stored securely in your digital home for easy audit access.

Your panel is assigned based on specialty alignment and capacity. We use a risk-stratification model to ensure balanced workload.

Panel Segmentation by Condition

• Preventive / Wellness: Annual visits, screenings.
• Chronic stable: Hypertension, diabetes, obesity (non-life-threatening).
• Post-operative: Follow-ups after low-risk procedures.
• Mental health: Anxiety, depression support (coordination, not therapy).

Retention & Engagement Metrics

Track patient satisfaction (NPS), adherence rates, and appointment show rates. High engagement correlates with better outcomes and panel growth.

Care Models & Income Examples

Per appointment income: $120 – $600 depending on complexity, time, and service type. Below are detailed examples with CPT codes and typical reimbursement ranges.

Note: These are estimates; actual reimbursement varies by payer and region.

As an independent contractor, your income is directly tied to the volume and type of appointments you conduct. Below are realistic scenarios based on a 200–500 patient panel.

Credit Line & Expense Management

The $5,000 internal credit line can be used for GoTo Telemed platform fees, training extensions, or marketing support. It is repaid from your earnings over time. The upfront $890 external cost is your responsibility and covers malpractice tail and state accreditation.

Sample Income Scenario Worksheet (Monthly)

Detailed Daily Checklist

• Start: Log into EMR, check secure messages, review AI-generated risk flags.
• Midday block: Conduct scheduled virtual check-ins (15-30 min each).
• Afternoon: Outreach to high-risk patients, coordinate referrals.
• End-of-day: Complete all notes, sign off on tasks.

Productivity Benchmarks

Expected: 4–6 completed patient interactions per clinical hour. Documentation within 24 hours. Quality audit score >90%.

Holistic Patient Assessment

Beyond clinical data, coordinators consider social determinants, behavioral health, and family support. AI prompts questions based on SDOH screening.

AI-Assisted Care Coordination

• AI triage: Analyzes incoming messages and vitals, suggests priority.
• AI documentation support: Ambient listening generates draft notes for review.
• AI-driven follow-up reminders: Automatically schedules outreach.
• AI risk flags: Identifies patients at risk; coordinator intervenes.

Human Judgment & Safety Checks: All AI outputs are reviewed by the coordinator. Supervising clinicians have final authority.

Compliance & Risk Management

HIPAA & Privacy: All communication through secure platform. Scope of Practice: Coordinators do not diagnose or prescribe. Incident Reporting: Report within 24 hours. Fraud & Abuse Avoidance: Document only services provided.

Value of Telehealth Care Coordination

Care coordinators reduce unnecessary ED visits by up to 30% and hospital readmissions by 20%. They improve medication adherence by 25% and patient satisfaction scores significantly.

Sample Daily Schedule

Sample Care Plan (Excerpt)

Patient: 67F, HTN, DM2. Goals: BP <140/90. Coordinator Actions: weekly check-in, medication reminders.

Glossary

RPM: Remote patient monitoring · CCM: Chronic care management.