Medical Assistant for Care Management

2 months ago

Brooklyn, United States Doral Health & Wellness Full time

***:
This position is responsible for managing high risk, chronic illness patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcome. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.

**ESSENTIAL DUTIES AND RESPONSIBILITIES**:

- Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.
- Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Prioritize patients according to intensity, need and required follow up.
- Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources, and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
- Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented.
- Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. Monitors and evaluates the progress of the patient.
- Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
- Identifies and effectively utilizes community resources to meet the needs of patients/families.
- Facilitates patient access to community resources as appropriate or refers to SW.
- Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
- Performs follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission.
- Maintains EMR databases on care managed population. Maintains accurate and timely documentation in the EMR
- Reviews utilization and quality reports routinely and scans for gaps in care to identify patients needing the additional support of care management.
- Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
- Performs medication reconciliation for all care transitions.
- Participates in regular team meetings and peer review activities. Participates in quality and organizational committees.
- Participates in the orientation of new personnel. Precepts and mentors’ peers. Promotes collaborative teamwork.
- Abides by the organization’s compliance program and requirements.
- Provides coverage across the organization as needed.
- Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.

**COMPETENCIES**:

- Good organizational skills to handle multiple priorities while remaining professional and calm.
- Ability to work with many diverse people.
- Effective telephone skills.
- Strong level of confidentiality due to the sensitivity of materials and information handled.
- Must be able to make suggestions on workflow or system efficiency and effectiveness.
- Ability to work independently and be self-directed and flexible.
- Ability to prioritize.
- Ability to perform functions with mínimal supervision.
- Ability to work at a high-volume level of accuracy.

**GENERAL EXPECTATIONS**:

- Be committed to the mission of Doral Health and Wellness
- Behave in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all members of the healthcare team. Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families of Doral Health and Wellness
- Be punctual for scheduled work and use time appropriately.
- Maintain confidentiality and protect the Practice by abiding by laws and principles related to confidentiality; keep information concerning Practice Operations, patients, and employees confidential.
- This position requires compliance with Health Center’s compl

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