Integrated Medical Services (IMS)·Phoenix, Arizona
The coordinator manages Transitional Care Management (TCM) and Chronic Care Management (CCM) workflows to reduce hospital readmissions for high-risk patients. Responsibilities include conducting patient outreach, performing medication reconciliation, and maintaining accurate clinical documentation in the EHR.
IMS Care Center is currently searching for a professional, compassionate and knowledgeable individual to fill the position of Integrated Care Coordinator for our Quality and Population Health team.
The Care Coordinator will be accountable for collaborating with the care team to consistently communicate and document high risk patient profiles to provider and teams.
You will work closely with the care team to collaborate on patient care.
The Integrated Care Coordinator bridges the gap between inpatient discharge and long-term wellness.
This dual-focused, 100% on-site role manages both Transitional Care Management (TCM) and Chronic Care Management (CCM) workflows for high-risk patients under general provider supervision.
The ideal candidate will eliminate barriers to care, drive clinical quality metrics, reduce hospital readmissions, and ensure strict compliance with Centers for Medicare & Medicaid Services (CMS) billing guidelines.
Immediate
Outreach: Initiate telephonic or secure digital contact with patients or caregivers within two business days of inpatient discharge.
Discharge
Review: Obtain and interpret facility discharge summaries, identifying critical medication changes or required follow-up labs.
Medication
Reconciliation: Perform comprehensive medication reconciliation on or before the face-to-face visit to prevent adverse drug events.
Appointment
Scheduling: Coordinate and secure a face-to-face follow-up provider appointment within 7 calendar days (high complexity) or 14 calendar days (moderate complexity) of discharge.
Barrier
Elimination: Provide resources to patients who may need information to resolve social determinants of health (SDOH), medical transportation or durable medical equipment (DME).
Care
Plan
Coordination: Collaborate with patients and providers regarding a comprehensive, patient-centered electronic care plan.
Monthly
Check-ins: When needed conduct structured monthly remote consultations (minimum 20 minutes) to track clinical status and treatment adherence.
Preventive
Tracking: Monitor and schedule proactive health interventions, including immunizations, wellness exams, and routine laboratory tests
Time-Tracking
Operations: Document and log precise, non-face-to-face interaction time.
EHR
Management: Maintain immaculate, accurate, and structured clinical documentation within the certified Electronic Health Record (EHR) system.
Assist and cross cover clinical team in clinics during staffing shortage.
Assignments may include but are not limited to: rooming patients, taking vitals, covering staff. inboxes for patient cases, answering patients calls, scheduling appointments.
Travel: limited travel in between different locations within IMS Care Center may be required.
Perform other duties as assigned.
You can look forward to a generous compensation package including medical, dental vision, short-term and long-term disability, life insurance, paid time off and a very lucrative 401K plan.
*IMS is a tobacco-free work environment
IMS is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sex, disability status, sexual orientation, gender identity, age, protected veteran status or any other characteristics protected by law. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Candidates must have a High School diploma or GED and a valid Certified Medical Assistant (CMA) credential. A minimum of six months of clinical experience is required, with preference given to those experienced in CCM or TCM programs.
Market context
Support-services jobs in Arizona often see steady demand in healthcare settings, especially when facilities need dependable staff who can work directly with patients and teams. These roles are competitive because employers commonly look for current Arizona CNA certification, CPR certification, and facility experience; this posting also notes a preference for more than one year in a skilled nursing facility. Review the AI-summarized requirements and benefits on this platform to save research time, and confirm your AZ fingerprint card is current before applying.
APP Nurse Practitioner or Physician Assistant-Primary Care
Endoscopy Technician-PRN
Vascular Technician