Medical Assistant - Care Gap Coordinator

Description The Medical Assistant's primary responsibility is to assist in the delivery of health care management for the health center. This includes actively participating in and supporting primary clinical teams, with a strong focus on improving patient outcomes through proactive care coordination. The Medical Assistant plays a key role in identifying, addressing, and closing care gaps, including preventive screenings, point of care testing, and vaccinations, and ensuring accurate documentation and data capture to support quality reporting and population health initiatives. Additionally, the Medical Assistant supports Chronic Care Management (CCM) initiatives by assisting in the coordination of care for patients with chronic conditions, contributing to monthly care management activities, and collaborating closely with the Licensed Practical Nurse (LPN) and care team to ensure appropriate tracking and documentation of CCM services. The Medical Assistant behaves in a professional manner and consistently demonstrates and promotes the values of the organization. The Medical Assistant will work with and receive supervision from the Medical Assistant Manager, Health Center Manager, and Clinicians. Become familiar with provider tendencies and provider's established patient's conditions Distribute Patient Agenda Complete medication reconciliation every visit, including over the counter meds Complete Family and Social histories Move patients from waiting room to treatment room Perform vital signs, acquiring any recent test results, and ascertain reason for visit Prepare patient and gathering all necessary information Identify, track, and take ownership of closing care gaps, including preventive screenings and vaccinations, in alignment with clinical guidelines and organizational quality measures Navigate Azara and other supplemental ACO tools appropriately identify and outreach patients for needed tests/screenings/appointments Ensure all care gap actions are accurately documented in the EMR and that appropriate data is captured and submitted to support closure of gaps in quality reporting systems (e.g., HEDIS, UDS, and other value-based care metrics) Coordinate with providers and care team members to complete required screenings, orders, and follow-ups needed to successfully close care gaps Educate patients on preventive care needs and assist with scheduling, completion, and follow-up to ensure gaps are fully closed Report any changes observed in condition or behavior of patient Prepare room for the practitioner Perform simple procedures according to Wright Center medical policy/procedures Give inoculations; draw blood, EKGs and /or any other provider requests Participate in quality assurance activities to monitor and improve patient care quality Complete any forms or growth charts as appropriate before practitioner sees patient Assist with examination, diagnostic and treatment procedures Enter requisitions in EMR Prepare and send out specimens Stock treatment rooms and all clinical areas as needed daily; alerting Health Center Manager of any supplies that need to be ordered Keep all exam rooms, hall, and lab area neat and clean Follow all standing orders as needed Facilitate spirometry, audiometry, BP checks, allergy shots, UA/UC, urine drug screens and other procedures that are necessary Attend all staff meetings Provide back-up to other co-workers as necessary Understand and adhere to professional office standards Be familiar with and implementing all office policies and procedures Participate when appropriate in unit-based quality initiatives Perform Laboratory testing Maintain a safe, secure, and healthy work environment by following standards and procedures and in compliance with legal regulations Comply with established personal protective equipment requirements necessary for protection against exposure to blood and other potentially infectious body fluids, chemical disinfectants, and other hazardous substances Prepare and administer medications and injections per provider Ensure patients understand health center resources and available programs, such as Sliding fee discount program Good Faith Estimate (GFE) Outreach & Enrollment programs Language services Ensure compliance in the following areas: Availability and location of SDS and 990 binders Understanding role and responsibilities in an emergency to help coworkers and patients to safety Make timely call backs and inform patients of their test results Work in close support of health center medical director, physicians, nurses, care manager and other providers Become familiar with HIPAA policies regarding privacy and security of patient health information that will always be exercised by this position Be responsible for registering and activating patients on their individual portal accounts Assist and guide patients to troubleshoot issues related to portal usage Schedule patient appointments and follow-up visits Answer and return phone calls Intake and check out of patients Ensure copays are collected at time of visit Create triages within the EMR system Participation in rotation of extended access hours including late nights, weekends and holidays Cross coverage of other locations and service lines for continued support and access for patients