Job Summary

Centered in a clinician provider practice, this individual acts as a collaborative member of the clinical team in providing continuity of and quality patient care. Initiates patient care assessments, gathers vital signs, prepares patient and exam room for procedures, and collects specimens. Coordinates care for patients with chronic disease and manages effective care transitions for them within the continuum. Partners with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. Provides effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk.

1. Assess problems/conditions during workup and accurately documents in medical records.
2. Assists provider in examination, treatment and referral of patient, preparing necessary paperwork, equipment, etc. This includes, but not limited to: giving injections, CLIA waived point of care testing, providing education, scheduling referrals and tests.
3. Responsible for ordering and maintaining adequate supply levels.
4. Responsible for training new clinical staff members within clinic.
5. Maintains and assists in coordinating clinical coverage within the clinic in conjunction with network leadership team.
6. Stratify patient population according to risk to effectively and efficiently manage patients, determine frequency of need for provider appointment. Maximize use of qualified clinical staff within the care management team for ensuring needed non-face-to-face patient contact.
7. Ensure effective office/clinic staff internal tracking of test/procedure results, medication acquisition, missed appointments and adherence to follow-up appointments.
8. Use ACO tools for office/clinic staff review of patients coming due for their Annual Wellness Visits (AWV). Ensure review of patient record to identify gaps in problem list prior to provider visit, post reminders to secure that all co-morbidities are discussed and documented during AWV.
9. Identify scheduling opportunities, determine special needs for patients arriving that office/clinic day, identify patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments needing rescheduling

Minimum Knowledge, Skills and Experience required:

Education: High School diploma or GED required; post-secondary education preferred, medical assistant certification preferred.

Experience: Previous 3 years medical experience, preferably in an office/clinic setting caring for chronic disease patients.