Integrated Care Coordinator

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.

Transitional Care Management:

• 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).

Chronic Care Management:

• 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.

Education/

Experience:

• High School diploma or GED
• Education/Licensure:
  Certified Medical Assistant (CMA) credential in good standing.
• Experience:
  
  Minimum six (6) months of clinical experience; experience working within CCM, TCM, or utilization of review programs preferred.

Required Knowledge,

Skills:

• Ability to work 100% on-site during standard operational hours.
• Proficiency with Electronic Health Record (EHR) platforms and ability to learn population health management analytics dashboard and access HIE portals.
• Exceptional telephonic communication, empathy, strong organizational multi-tasking.
• Requires exceptional interpersonal and communication skills.
• Ability to interact with people from different backgrounds and cultures.
• Requires the ability to manage multiple changing priorities in an effective and organized fashion.
• Must have knowledge of and always follow HIPAA guidelines and secure Protected Health Information.
• The ability to work in a constant state of alertness and in a safe manner.

Joining IMS is more than saying "yes" to making the world a healthier place. It's discovering a career that's challenging, supportive and inspiring. Where a culture driven by excellence helps you not only meet your goals but also create new ones. We focus on creating a diverse and inclusive culture, encouraging individuals to expression in the workplace and…