Care Coordinator

Care Coordinator – Hybrid Position (Remote and In-Person)

Provider-Centered. Patient-Focused. Built for What Healthcare Should Be.

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.

Care Coordinators will be a vital member of the team providing exceptional care to our patients. This role will work collaboratively with the primary care provider and all members of the health care team to promote quality care and close care gaps. The care coordinator will identify patient care needs, implement the plan of care, and communicate with patients in person and via phone as well as perform specific clinical tasks and procedures in the office setting.

This position is responsible for identification of patients appropriate for Annual Wellness Visits (AWV) and execution of guided processes to complete the visit. Responsibilities also include coordinating patient care to improve quality of care through the efficient use of resources and acting as an advocate for the individual's healthcare needs.

Essential Job Functions, Duties, and Responsibilities:

The following list of duties is not intended to be restrictive or all inclusive.

• 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

Minimum Qualifications:

Education:

• Associate degree preferred
• Current CPR /BLS

Experience:

• 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

License:

• If applicable -Current nursing licensure in good standing in AZ

Must Have:

• 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

Skills & Abilities:

• 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

Why You Will Love Working Here:

We take care of our team so they can take care of patients. Benefits include:

• Medical, dental, and vision coverage
• Company funded HSA + exclusive healthcare discounts
• 401(k) with company match
• Company paid life insurance
• Flexible time off + Vacation Exchange Program
• Medical Assistant Certification Reimbursement

What We Value:

Trust. Ownership (Together). Compassion. Relentless Progress. These values shape how we show up for patients — and for each other.

Bookmark Medical is committed to a workplace that supports and sustains inclusion and belonging. Bookmark Medical does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, national origin, age, physical or mental disability, pregnancy, childbirth or related medical conditions, military service obligations, citizenship, sexual orientation, genetic information, or any other characteristic protected by applicable local, state, or federal law.