Care Coordinator - Chronic Management

Optima Medical Ltd; Sierra Vista (AZ); On-site; USD 38,000 - 60,000; Full time

Benefits offered by this job

Medical coverage

Vision and dental insurance

401(k) with paid holidays

Job summary

Optima Medical Ltd in Arizona is seeking a Care Coordinator for an in-office, phone and EMR-based coordination role supporting patients with chronic conditions. You will develop care plans, coordinate with providers, and monitor adherence.

This is ideal for Medical Assistants seeking to advance their careers while applying clinical knowledge daily. The role emphasizes outreach, follow-up, and collaboration with a multidisciplinary team, using EHR tools to document care.

Qualifications

• At least 1 year of clinical work as a Medical Assistant.
• At least 1 year of EMR experience; eClinicalWorks preferred.
• High level of professionalism.
• HS diploma or GED equivalent; CMA designation preferred.

Responsibilities

• Develop personalized care plans with patients, caregivers, and providers.
• Coordinate and facilitate communication among physicians, nurses, and other team members.
• Monitor adherence to treatment plans and progress toward health goals.
• Provide ongoing education and support on disease management and preventive care.
• Document patient encounters using EHR and ensure continuity of care.
• Collaborate with community resources to address social determinants of health.
• Conduct regular follow-up check-ins and care coordination activities.

Skills

Medical Assistant

EMR experience

Professionalism

Communication skills

Bilingual (English/Spanish)

Education

HS diploma or GED

Medical Assistant Course Completion Diploma or CMA designation

Tools

eClinicalWorks EMR

Job description

Optima Medical is an Arizona-based medical group consisting of 30 locations and over 130+ medical providers, who care for more than 200,000 patients statewide. Our mission is to improve the quality of life throughout Arizona by helping communities "Live Better, Live Longer" through personalized healthcare, with a focus on preventing the nation’s top leading causes of death. We go beyond primary care with a full spectrum of services including cardiovascular health services, behavioral health, allergy testing and immunotherapy, in-house lab testing, imaging, chronic disease management, and other specialty health services. We aspire to aid the growth of our company by welcoming the most qualified and deserving candidates aboard. Optima is currently seeking a Care Coordinator to join our team! This individual will be expected to monitor a specific group of patient’s care and support them in achieving short/long term health goals. The Care Coordinator will coordinate with providers to ensure patients’ needs are met. A working knowledge of the clinical field is desired for this position.

About the Role:

This is an in office phone and EMR-based coordination role — not a traditional clinical floor position. As a Care Coordinator in our growing CCM program, you’ll work directly with patients living with chronic conditions (such as diabetes, hypertension, COPD, and heart disease), helping them stay on track with their care plans and health goals through regular outreach and follow‑up. This is a fantastic opportunity for Medical Assistants looking to take the next step in their career while still using their clinical knowledge every day.

• Developing personalized care plans in collaboration with patients, caregivers, and healthcare providers.
• Coordinating and facilitating communication between various healthcare team members, including physicians, specialists, nurses, and ancillary service providers.
• Monitoring patients’ adherence to treatment plans and medications, as well as their progress towards health goals.
• Providing ongoing education and support to patients and their families regarding disease management, lifestyle modifications, and preventive care measures.
• Utilizing electronic health records (EHR) and other healthcare technology tools to document patient encounters, track interventions, and ensure continuity of care.
• Collaborating with community resources and social services agencies to address patients’ social determinants of health and support their overall well‑being.
• Conducting regular follow‑up check ins and care coordination activities to optimize health outcomes and quality of life for patients with chronic conditions.

Care Coordinator Qualifications:

• At least 1 year of clinical work experience as a Medical Assistant
• At least 1 year of EMR experience; eClinicalWorks preferred
• High level of professionalism
• Excellent written and verbal communication skills
• Medical Assistant Course Completion Diploma or CMA designation required
• Bilingual (English/Spanish) is a plus
• Must have HS diploma or GED equivalent

Why Join Our Team?

• Leadership and mentoring
• Resources to further your career
• Benefits (medical/vision/dental/401k/paid holidays)
• Supportive and positive work environment