Care Coordinator

RHC Group Management LLC•Mesa, AZ

12d•Hybrid

About The Position

At Bookmark Medical, we are building a healthcare experience rooted in trust, teamwork, compassion, and continuous progress. We believe the best care happens when providers and care teams have the support, technology, and resources they need to focus on what matters most—patients. Our mission is simple: improve lives through high-quality continuous care. Through connected care teams, innovative tools, and collaborative culture, we are creating a healthcare experience where patients are known, supported, and never have to start over. Whether you are caring directly for patients, supporting operations, or helping grow our organization, you will join a team that values your expertise, encourages your growth, and empowers you to make a meaningful impact every day. If you are looking for more than just a job, if you are looking for a purpose-driven career where your work truly matters, we would love to meet you.

Requirements

Associate degree preferred
Current CPR /BLS
Minimum of 2-3 years of experience as a Medical Assistant or Licensed Practical Nurse
Experience in primary care, chronic care/disease management, or care coordination preferred
If applicable -Current nursing licensure in good standing in AZ
Knowledge of primary health care and the social determinants of health
Knowledge of HEDIS measures and CMS Star Ratings Methodology
Knowledge of concepts of health promotion, disease prevention, chronic disease management, care coordination and transitions of care
Health coaching or motivational interviewing
Knowledge and awareness related to cultural competence
Ability to work independently and be self-directed
Ability to collaborate and work well with other healthcare professionals
Ability to be an effective change agent
Effective organizational, critical thinking, problem-solving and decision-making skills
Excellent communication skills and ability to adapt communication styles to meet the needs of patients, healthcare team members and community partners
Proficient in EMR documentation and computer/technology savvy

Responsibilities

Perform interview and patient intake to gather medical information
Utilize patient medical information to prepare for and/or provide care based upon patient visit or encounter needs
Identify patients appropriate for care management or transitional care management services
Perform therapeutic point of care diagnostic testing and other relevant clinical tasks as ordered for patients
Interact professionally in person and telephonically with patient/family to inform, educate, counsel to plan of care
Communicate, coordinate, and consult with members of the health team to eliminate barriers to care delivery and meet individual patient’s healthcare needs
Maintain accurate and timely documentation of the patient’s care in the EMR
Focus clinic efforts on patient satisfaction, clinical quality measures, HEDIS, and meaningful use standards
Provide high intensity engagement with patients and family and serve as a patient advocate
Follow Annual Wellness Visit protocols and standing orders including completion of preventive services as appropriate
Perform medical record reviews to look for gaps in care such as missing mammograms, colon cancer screenings, diabetic screenings, etc.
Coordinate with provider and clinical team to inform of missing screenings and HEDIS gaps
Address open quality gaps with patients and works collaboratively towards closure
Utilize incoming reports of emergency room utilization, hospital/facility discharges and medical information to initiate transitional care management activities and plan of care
Submit/report patient information to various health plans via their portals
Comply with federal, state, and local regulatory requirements and participates in the preparation and conduction of clinic or program regulatory audits
Assist with all quality measure initiatives
Assist as needed with other clinical duties such as prior authorizations, referrals, patient messages, prescription refills