Essential Duties:

Works with Care Coordination RN/LVN to promote and reinforce patient centered medical home (PCMH) concepts with patients and staff.
Coordinates care for designated patients by collaborating with MHM primary care providers, the integrated healthcare team, specialists, Clinical CHWs, Wesley Nurses, patients, and families to ensure seamless navigation through the healthcare system.
Support patients in navigating follow-up care after an ER visit, including scheduling appointments, managing medication needs, and assisting in the coordination of specialty referrals to ensure effective care transitions.
Follow established processes aimed to improve patient's health outcomes.
Provide education to patients and/or family regarding patient's condition and ongoing care.
Responds to inquiries and calls from patients, providers, integrated healthcare team and external resources.
Assists in the resolution of complaints, requests, and inquiries from patients.
Monitor patients for changes in clinical symptoms in-person at clinic, at home or by phone.
Conducts home visits as needed to assess patient needs, provide support, promote continuity of care and improve patient's health outcomes.
Work with external agencies for welfare checks when appropriate.
Occasionally takes and documents patient vital signs (blood pressure, pulse, weight, height, other measures as assigned) both in the clinic and patient's home setting.
Document tracked patient outcomes using accurate and appropriate clinical terminology.
Assist with transition of care to ensure continuity and support as patients move between healthcare settings.
Performs other duties as assigned.

Qualifications:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Education/Experience:High school diploma or general education degree (GED) required. Graduation from an accredited Medical Assistant program is also required. One year of experience in a clinical setting is required.Language Ability:Proficient in reading and interpreting documents with strong attention to detail, and capable of composing clear and concise written correspondence. Skilled in effectively presenting information in one-on-one and small group settings, particularly in interactions with patients, clients, providers and team members. Experience in providing verbal translation between providers and patients/clients is essential to ensure accurate and culturally appropriate communication. Fluency in English is required, and bilingual proficiency in Spanish is mandatory for this role.Reasoning Ability:Ability to apply understanding to carry out instructions. Ability to deal with standardized situations with occasional or no variables.Certificates and Licenses:Currently registered by either of the following: The Texas Department of Aging and Disability Services, National Association for Health Care Professionals, or National Healthcare Association required. BCLS certification required.Computer Skills:Individual should have basic knowledge of the Internet and Microsoft Office applications, including Outlook, PowerPoint, Word, and Excel. Experience with electronic health record (EHR) software is preferred.Other:Must have a valid driver's license, access to a reliable vehicle, and current auto liability insurance.Work Environment and Physical Demands:The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.This position is based in a medical office setting and involves direct interaction with patients and clients. Duties may require physical activities such as bending, stooping, twisting, turning, walking, using step stools, reaching, kneeling, crouching, sitting, and standing for extended periods. The role also requires the ability to lift and maneuver up to 25 pounds.

eQuest

Medical Assistant Care Coordinator (WHWC)

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