Medical Assistant - Chronic Care Management (Temp-To Hire)

Sante Health•Fresno, CA

12d•$17 - $24

About The Position

Sante Health System is seeking a Medical Assistant in Fresno, California, to support its Chronic Care Management (CCM) program. The role collaborates with staff, physicians, and management to serve eligible patients according to insurance guidelines, promote patient engagement and satisfaction, meet quality outcome metrics, and support accurate reimbursement capture. CCM services are provided under the direction of a physician. The Medical Assistant helps identify eligible patients, complete monthly CCM calls, coordinate care and follow-up, educate and navigate patients, and support patient self-management. The role also maintains patient records, monitors changes in patient circumstances, shares relevant information with the care team, and contributes to process improvement, quality assurance, and program sustainability. Sante Health System is a Management Services Organization serving multiple clients and coordinating with physicians, health plans, hospitals, and other providers. The organization describes a service-driven workplace and offers competitive pay, benefits, paid time off, and opportunities for advancement. The position is listed as temp-to-hire.

Requirements

High school diploma or GED equivalent.
Graduation from an accredited Medical Assistant program.
Exceptional people and communication skills.
Ability to multitask in a fast-paced environment.
Commitment to accuracy and attention to detail.
Knowledge of community health concepts, community healthcare principles, care coordination, and epidemiology.
Knowledge of organizational policies, regulatory requirements, and procedures for administering patient care.
Knowledge of common safety hazards and precautions for establishing a safe work environment and evaluating home care.
Skill in health interviewing, teaching, and verbal and written communication.
Skill in identifying problems and recommending solutions using established protocols and sound judgment.
Skill in preparing and maintaining records, writing reports, and responding to correspondence.
Skill in developing and maintaining site quality assurance.
Skill in establishing and maintaining effective working relationships with patients, medical staff, and care team members.
Ability to react calmly and effectively in emergency situations.

Nice To Haves

Certification from the American Association of Medical Assistants.
At least two years of experience; preferred but not required.
Epic EMR experience.
Bilingual English/Spanish ability.

Responsibilities

Develop an efficient CCM process for patient identification, communication, scheduling, and follow-up in collaboration with physicians and office staff.
Support identification of eligible patients and complete monthly CCM calls according to best-practice guidelines.
Ensure CCM calls are coded accurately to support financial capture.
Provide age-based, culturally and linguistically appropriate patient education; help patients navigate the healthcare system and community as a patient advocate and navigator.
Encourage and facilitate patient disease self-management, behavior modification, and home monitoring within the scope of CCM.
Maintain CCM sustainability and process improvement, and make referrals as appropriate.
Complete comprehensive, age-appropriate reviews based on patient strengths, goals, needs, health conditions, environment, and psychosocial determinants of health.
Monitor patient responses to care plans or services and changes in biophysical, psychosocial, family, or environmental status; notify the RN/LVN and ensure relevant participants are informed.
Provide general information about department policies and procedures.
Maintain patient files, records, and other information.
Attend required meetings and participate in committees as requested.
Participate in professional development activities and maintain professional affiliations.
Follow all Medical Assistant competencies, System policies and procedures, and System Values.
Maintain patient confidentiality in compliance with HIPAA regulations.
Perform other job-related duties and follow other job-related instructions as requested.