Essential Duties & Responsibilities:

Patient outreach and monitoring by conducting monthly telephonic or digital check-ins (typically 20+ minutes) to monitor health status and adherence to care plans.
Identifies program eligibility
Performs medication reconciliation and verify compliance, ensuring patients understand their prescriptions and identifying potential drug interactions.
Schedule follow-up appointments, facilitate specialist referrals, and coordinate community resources like transportation or home care.
Follows up with preventative screenings.
Support patients during transitions of care, such as follow-up after a hospital discharge or ER visit.
Provides effective clinical health coaching to assist the patients with self-management of their chronic disease and life-style changes to mitigate health risks.

Education:

High School Diploma/GED required, Vocational/Technical degree as Medical Assistant or Related field required.

Certification/License:

Certified Medical Assistant (CMA) required. CPR preferred.

Experience:

At least 1 year experience as MA in a Clinic/Office is preferred. Strong understanding of chronic conditions (diabetes, heart disease, CHF) and medical terminology. Excellent phone etiquette, active listening, and the ability to explain complex medical information in simple terms. Proficiency with EHR systems and Microsoft Office applications. Empathy, strong organizational skills, and the ability to work independently in a fast-paced or remote environment.

The Chronic Care Management Medical Assistant will serve as a vital liaison between patients, their families, and the multidisciplinary clinical team. You will facilitate a shared goal model of care, ensuring seamless coordination for patients with chronic diseases and managing transitions of care to optimize health outcomes.

This position focuses on providing essential non-face-to-face care coordination and support to help patients effectively manage chronic illnesses, reduce hospitalizations, and improve their overall quality of life. Key responsibilities include conducting regular monthly outreach, providing patient education, and maintaining precise clinical documentation in accordance with Medicare guidelines. By partnering closely with providers, you will deliver proactive clinical health coaching to assist patients with self-management and lifestyle modifications, ultimately mitigating health risks and preventing avoidable acute illnesses.

Monday through Thursday, 8a-5p and Friday 8a-12p