The Clinical Documentation Improvement (CDI) / Population Health Medical Assistant supports value-based care initiatives by assisting with pre-visit chart preparation, care gap identification, documentation accuracy, and population health outreach. This role focuses on ensuring that preventive care services, chronic disease monitoring, and quality metrics are appropriately identified and addressed within the electronic medical record (EMR). The CDI Medical Assistant works collaboratively with providers, clinic-based medical assistants, quality improvement teams, and population health staff to support closed-loop care gap workflows and improve clinical documentation that impacts quality measures, regulatory compliance, and value-based reimbursement programs. Key Responsibilities Pre-Visit Chart Preparation Conduct full pre-visit chart preparation for scheduled patient appointments. Review the electronic medical record (EMR) to identify preventive care, chronic disease monitoring, and documentation gaps. Verify accuracy of health maintenance records, problem lists, and clinical documentation prior to patient visits. Review care gap reports, EMR alerts, and population health registries to identify patients with outstanding care needs. Prepare visit notes or EMR alerts highlighting outstanding care gaps for provider review. Care Gap Identification and Closure Support Assist with identification and documentation of care gaps including but not limited to: Preventive screenings (mammography, colorectal cancer screening, etc.) Immunizations Diabetes monitoring (A1C, retinal exams, microalbumin) Blood pressure documentation Depression screening (PHQ-9) Annual wellness visits and preventive services Other care gaps as assigned. Prepare pending orders for provider review when appropriate. Coordinate with clinic-based MAs to support completion of screenings and documentation during patient visits. Documentation Quality and Data Integrity Ensure clinical documentation supports quality measures and value-based care requirements. Verify that structured data elements such as vitals, BMI, screening results, and health history are accurately entered in the EMR. Support accurate problem list updates and documentation consistency. Assist with documentation workflows that support

HEDIS, CMS

Star Ratings, and risk adjustment initiatives. Population Health and Care Coordination Support Assist with tracking and follow-up of incomplete labs, referrals, or imaging related to identified care gaps. Conduct patient outreach to support scheduling of preventive services and follow-up appointments. Support closed-loop referral tracking to ensure completion of recommended services. Document outreach activities and patient communications in the EMR. Quality and Population Health Reporting Support Review care gap reports, registries, and population health dashboards. Assist in validating report data and identifying patients needing outreach. Support scheduling efforts to close identified care gaps. Collaboration and Communication Work closely with providers, clinic-based medical assistants, and quality improvement teams to support care gap closure. Coordinate with Community Health Workers (CHWs) when social support or additional patient outreach is required. Communicate identified care gaps or documentation issues to appropriate clinical teams. Required Certified Medical Assistant (CMA/RMA) or equivalent credential. Experience working in ambulatory care or primary care settings. Familiarity with Electronic Medical Records (EMR). Strong attention to detail and documentation accuracy. Ability to manage multiple tasks and maintain organized workflows. Preferred Experience with population health, care gap management, or quality improvement initiatives. Knowledge of HEDIS measures, preventive care guidelines, and value-based care programs. Experience with patient outreach and care coordination workflows. Key Competencies Clinical documentation accuracy Population health awareness Quality metric compliance Care coordination Communication and teamwork Attention to detail Workflow organization Department Goals The CDI / Population Health Medical Assistant role supports organizational initiatives focused on: Improving clinical documentation accuracy Increasing care gap closure rates Enhancing preventive care delivery Supporting value-based care programs Improving performance on quality measures such as

HEDIS and CMS Star Ratings Department:

Clinical Documentation Improvement (CDI) /

Population Health Reports To:

Director of Patient Services FLSA Status:

Non-Exempt Position Type:

Full-Time Working Schedule:

Monday-Friday, 8:00 AM-5:00

PM Pay:

$24.00 - $26.00 per hour

Benefits:

401(k) matching Dental insurance Health insurance Vision insurance

Work Location:

In person