Position Purpose: The Population Health Medical Assistant conducts the coordination of care to improve Hemoglobin A1c, Preventive Oral Health Visits and Pap Smears for patients within disease specific populations. He or she is responsible for the development, implementation and alignment of CHI goals and the existing quality improvement efforts and support the achievement of PCMH recognition by using data to better manage our patient population.

POSITION REQUIREMENTS / QUALIFICATIONS:

Education/Experience:Experience working with culturally diverse clients. Working knowledge regarding Joint Commission, NCQA, HEDIS, UDS requirements. An ability to learn and understand those standards and elements. Prior experience working with patients with chronic conditions preferred.

Licensure / Certification:Certified as a Medical Assistant in the State of Florida. Maintain current CPR certification from the American Heart Association. Must have a valid Florida Driver’s License.

Skills / Ability:Excellent communication and interpersonal skills. Sensitivity in working with diverse cultural groups. Demonstrate excellence in both internal and external customer service, adhere to national patient safety goals as defined by the Joint Commission. Ability to present ideas and recommendations clearly and concisely in writing and orally. Excellent interpersonal communication skills. Proven ability to problem solve and solution oriented. Strong ability to work independently and as a team member with fellow co-workers, supervisors, and other staff. Able to take and follow through with delegated tasks and accountability. Demonstrates flexibility in work schedule and job assignments. General working knowledge of utilization management, performance improvement standards and procedures and NCQA Standards. Experience with managing competing priorities. Medical terminology. Strong computer skills required. Bilingual preferred.

POSITION RESPONSIBILITIES (NON-EXEMPT POSITION):

Attends orientation sessions, scheduled meetings, and face-to-face consultation with supervisor.

Consistently gives attention to detail.

Assist the Population Health department in orienting and educating patients and their families on the importance of routine diagnostic testing in addition to screening tests and visits such as Hemoglobin A1c, Preventive Oral Health Visits and Pap Smears. 

Assist in coordination and care requirements for patients within the disease specific populations.

Responsible for documentation of and scheduling of tests and diagnostic services and interacting with members of the care team to ensure that tests, procedures, and consults are completed. 

Responsible for maintaining a database to track patients when they obtain services in an emergency department, hospital, or other healthcare facility. 

Under the direction of the clinicians, they communicate care plans to patients and their families. 

Coordinates home visits if warranted for non-compliant patients.

Assist in providing relevant self-management support for patients with chronic illnesses identified by the clinical team. 

Assist families to access the health care system and assign to a medical home.

Assist with data collection and generation of patient registry reports. 

Communicate effectively and expresses ideas clearly; actively listens and always follows appropriate channels of communication.

Work with patients both in person and over the phone to remind and review their plan of care and progress towards achieving their goals.

Maintains flexibility to access families during non-traditional hours.

Collects and report results of outcomes and referrals, i.e., A1c, Pap Smears and Preventive Oral Health Visits, etc.

Collects specific data as required to meet the goals of the program.

Maintains accurate records of the activities performed.

Follow-up and track missed appointments.

Track coordination of referrals for outcome results.

Provides documentation of any patient contact when abnormal results are followed-up.

Attends scheduled in-services and trainings.

Works to achieve patient outcome goals as established in the Section 330 Health Care Plan.

Promptly informs supervisor of problems encountered in the line of duty.

Follows CHI Policies and Procedures.

Maintains 100% of monthly productivity goals.

Reports to work on time and ready to work with minimal absenteeism.

Assist Population Health Department with meeting deliverables for clinical intervention grants and goals.

Adheres to Confidentiality Policies and Procedures / HIPAA Regulations.

Treats patients with respect and dignity.

Participates in patient/community education (internal and external) and home visits when necessary.

Performs other duties as assigned.