Medical Assistant, Care Management

About the position

We are committed to building the best primary care environment for patients and are seeking healthcare enthusiasts to join us. Perform care management for patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize patient health care across the care continuum.

Responsibilities

• Structural recording of patient's health information and keeping care plan in EMR
• Managing transition of care services post hospital discharge, ER, SNF, include PCP appointment, Medication Reconciliation Post Hospital Discharge (MRP) completion, and specialist follow up
• Assist with identifying high risk population (i.e., high utilizers, multiple co-morbidities, polypharmacy, non-compliant, oxygen dependent, bed and wheelchair bound etc...)
• Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals during assessment(s) for patients enrolled in Care/Disease Management
• Provide patients with education based on medical condition and co-morbidities
• Ensures patient access to appropriate resources (i.e. community resources, social services, behavioral etc...)
• Participate in Interdisciplinary Care Team (ICT) meetings with patient's provider to communicate patients progress with his/her treatment plan, discuss complex issues or barriers to care
• Assist in utilization for high-risk population.
• Accurately updating and maintain team Share-point and Case/Disease Management cases
• Implement activities to promote cost savings such as potentially prevent admissions by coordinating outpatient care, reduce readmissions (Target 10%), improve Generic Dispensing Rates, improve staff competence by providing educational resources; balancing work requirements with learning opportunities; evaluation the application of learning to changes in treatment results

Requirements

• High school education or higher
• At least two years of related work experience are preferred
• Licensed: Medical Assistant, LPN, Health Coach, or CNA