Position Summary The Population Health Medical Assistant works in collaboration with primary care providers and healthcare team in providing a care model that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, protocols and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the assigned patient population. Reviews patient charts for screening needs and quality gap closure as well as care coordination needs. Places orders for screenings under the direction of a primary care provider. Facilitates referrals, coordinates services, and schedules patient visits for campaigns such as annual wellness visits, well child visits, and preventative screenings. Assists with data management for the Population Health initiatives. Minimum Qualifications Work Experience Previous clinical experience in a physician practice preferred.
Education Completion of a Medical Assistant, Certified Nursing Assistant, or equivalent training program required. A combination of work experience and on-the-job training in a physician practice environment may serve in lieu of the required training program.
Certifications/Licensure Registered Medical Assistant preferred. Job Specific Performance Standards The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.
  Documents patient information and communicates to healthcare providers as Triages patients (including obtaining vital signs), follows standing orders for facility, and assists with preparation for examinations and special procedures. Assists in managing patient populations in MCHP value-based agreements. Reviews attribution to determine if patient is correctly Contacts assignable patients to schedule with appropriate provider. Works with payers to update attribution. Participates in patient education by providing literature or training regarding medications, use of supplies, etc. Preps daily schedules for primary care to determine care gaps or annual wellness visits Sends prepped schedules to the practice manager daily. Contacts the patient to do pre-visit Reviews and updates problem list. Orders tests or labs as appropriate. Documents all HCC codes as appropriate. Provides feedback to providers about chronic codes that should be documented. Reviews and documents SDOH. Completes and documents patient referrals per department procedure.   Works with coding to ensure correct codes are dropped for CPTs, CPTIIs, and ICD-10s. Provides feedback to provider as necessary. Completes agendas, member summaries, and provider assessment forms as applicable. Works with Wellcare pharmacy in RX effect.   Performs transitional care for discharged patients. Attends routine meetings with payer representatives and reports progress. Completes weekly dashboard to ensure metrics are being met.