Medical Assistant/ECM (Enhanced Care Management) Care Coordinator

Description

The Medical Assistant (MA) supports the nurses and care teams with the daily management of non-clinical nursing and patient care functions. The MA also covers care teams with patient schedules as needed. The ECM (Enhanced Care Management) Care Coordinator duties are designed to provide holistic and integrated support to patients, ensuring they receive coordinated care across medical, behavioral, and social domains.

Medical Assistant:

• Process disability forms
• Run reports on health maintenance indicators such as overdue paps, mammograms, immunizations, and others while using appropriate tools to track
• Review follow up specialty consultation reports and update history, problem and medication lists
• Assist nurses with case management activities such as completing orders and forms for durable medical equipment, IHSS and communication with patient as needed
• Responsible for management of ER/UCC patient lists
• Assist the nurses with scanning, faxing, and other activities to ensure any patient documents are processed in a timely manner
• Provide outside facilities with missing patient demographic, insurance and clinical information necessary for providing services
• Maintain high level of communication with clinical team in regard to patient care and safety issues
• Assist with process of panel reassignment including patient communication as needed
• Cover care team medical assistants whenever staffing is needed with patient schedules and/or in-basket tasks
• Assist Quality Improvement department with patient recalls, chart review for QI measures and audits, as needed.
• Other duties as assigned.

ECM (Enhanced Care Management) Care Coordinator: 

• Coordinate care for patients with complex medical, behavioral, and social needs.
• Develop, implement, and monitor individualized care plans tailored to the patient's unique needs and goals.
• Collaborate with interdisciplinary teams including primary care providers, and behavioral health team members to ensure comprehensive care.
• Act as a liaison between patients, healthcare providers, and community services.
• Advocate for patients to access necessary services and support, such as housing, food assistance, transportation, and mental health resources.
• Help patients navigate the healthcare system, including follow-up care, specialty appointments, and referrals.
• Offer guidance and support on self-care practices to improve patient outcomes.
• Proactively engage with patients who are at high risk for hospitalization or other adverse health outcomes to ensure they remain connected to care.
• Conduct outreach to locate and engage patients who are difficult to reach
• Assess and address social determinants of health (SDOH) that impact the patient’s well-being, such as food insecurity, homelessness, or lack of access to transportation.
• Connect patients to community resources and social services that address these non-medical needs.
• Maintain accurate and up-to-date records of patient interactions, care plans, and referrals.
• Ensure timely documentation in the electronic health record (EHR) and prepare reports for internal tracking and compliance with external reporting requirements.
• Participate in regular interdisciplinary care team meetings to discuss patient progress, barriers, and opportunities for care improvement.
• Provide input on care coordination best practices and help refine care pathways based on patient needs.
• Respond to urgent situations where patients may be in crisis, such as potential hospitalizations, emergency department visits, or behavioral health crises, and help coordinate access to care to support improved outcomes. 
• Participate in quality improvement initiatives to enhance care coordination processes and improve patient outcomes.
• Monitor patient satisfaction and identify areas for service improvement within the care management program.

Requirements

• H.S. diploma and active Medical Assistant Certification
• 1 Year Medical Assistance experience in a healthcare facility preferred
• Bilingual in Spanish / English Required
• Ability to write routine reports and correspondence using electronic health record, working knowledge in EHR/EPIC a plus