CMA - Care Coordinator

CareAbout

5d•$19 - $26•Onsite

About The Position

The CMA- Care Coordinator (CMA-CC) facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician and Registered Nurse, the CMA-CC coordinates care for patients needing support by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite valuable, appropriate, and cost-effective care. The CMA-CC will work on a multidisciplinary healthcare team in a primary care setting, focusing on coordination of care for patients needing navigation and follow up after a hospitalization. They will support the clinical and operations teams in the care of patients. They will engage patients and take an active role in improving the health of patients we serve. They will partner with the care team in providing the patient with the tools necessary to make healthy lifestyle choices, adopt life-long healthy behaviors, and close gaps in care, and reduce unnecessary ER utilization and hospital admissions/readmissions.

Requirements

Certified or Registered Medical Assistant
Familiar with EKG, Phlebotomy and Patient Care
EHR and EMR systems.
Basic PC skills (MS Word/Outlook/PPT/Excel)
Ability to use independent judgment and to manage and impart confidential information.
Ability to analyze and solve problems; requires details, data and facts.
Ability to clearly communicate medical information to professional practitioners and/or the public.
Strong organization, prioritization, follow up, and time management skills
Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
Ability to deal with multiple interruptions on a continual basis must be met with a friendly exchange with others.

Nice To Haves

At least 2 years of similar job experience in a medical office preferred

Responsibilities

Monitor and identify patients who are eligible for Transitional Care Management following hospital or qualifying post-acute discharge.
Complete the required interactive contact with the patient and/or caregiver within the applicable TCM timeframe.
Establish contact with patients and caregivers by telephone or other approved communication methods.
Review and reinforce discharge instructions and identify questions, concerns, or barriers requiring attention by the care team.
Confirm the patient's understanding of the discharge plan and follow-up recommendations.
Identify medication-related concerns, access issues, or discrepancies and communicate them to the appropriate provider or clinical team member.
Assist with arranging and confirming timely follow-up appointments with the primary care provider.
Coordinate with providers, nurses, care managers, specialists, pharmacies, hospitals, and other healthcare entities as appropriate to support continuity of care.
Identify potential barriers to a successful transition, including transportation, medication access, difficulty obtaining services, or other non-clinical needs, and communicate those barriers to the appropriate care team member.
Escalate clinical symptoms, changes in condition, or other patient concerns to the appropriate licensed clinical staff or provider in accordance with established protocols.
Track TCM patients and follow established workflows to ensure required activities are completed within applicable timeframes.
Accurately document all patient contacts, assessments within scope, interventions, communications, and follow-up activities in the EHR/EMR.
Support care team efforts to reduce avoidable emergency department utilization, hospitalizations, and readmissions.
Assist with care-gap closure, preventive care outreach, chronic disease management activities, and other population health initiatives as assigned.
Participate in care team meetings, huddles, and other activities related to patient care coordination.
Maintain awareness of appropriate resource utilization and the total cost of care when coordinating services and supporting patient needs.
Maintain patient confidentiality and comply with HIPAA, organizational policies, and applicable regulatory requirements.
Perform other duties as assigned in support of the care team.