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

Sante Health•Fresno, CA

9d•Onsite

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 in accordance with insurance guidelines, promote patient engagement and satisfaction, meet outcome quality metrics, and support accurate reimbursement. The Medical Assistant helps identify eligible patients, conduct monthly CCM calls, coordinate scheduling and follow-up, and provide culturally and language-appropriate education. The role supports patients as an advocate and navigator, encourages self-management and home monitoring within the CCM scope, maintains records and patient files, and contributes to program sustainability and process improvement. CCM services are provided under the direction of a physician, with new patient information shared with the RN/LVN and relevant care-team participants. Sante Health System is a management services organization serving multiple clients and coordinating with physicians, health plans, hospitals, and ancillary providers. The organization describes its work culture as talented, driven, dedicated, innovative, and service-oriented.

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 with 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 the home-care environment.
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.
Ability to establish and maintain effective working relationships with patients, medical staff, and care-team members.
Ability to react calmly and effectively in emergency situations.
Ability to provide CCM services under the direction of a physician.

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 skills.

Responsibilities

Develop an efficient CCM process for patient identification, communication, scheduling, and follow-up in collaboration with physicians and office staff.
Help identify patients eligible for CCM and complete monthly calls according to best-practice guidelines.
Ensure CCM calls are coded accurately to support financial capture.
Provide age-based, culturally and language-appropriate patient education.
Help patients navigate the healthcare system and community as a patient advocate and navigator.
Encourage and facilitate patient 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 of patient strengths, goals, needs, health conditions, environment, and psychosocial determinants of health.
Monitor responses to care plans or services and changes in patients’ biophysical, psychosocial, family, or environmental status.
Notify the RN/LVN of new information and ensure participating patients, families, and care-team members 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 MA competencies, comply with System policies and procedures, and maintain patient confidentiality in accordance with HIPAA.
Demonstrate System Values and perform other job-related duties as requested.