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Job Summary:

The EverCare Medical Assistant (MA) is a key member of the interdisciplinary EverCare geriatric primary care team, which delivers primary care to residents of assisted living, adult foster care, and other facilities. The MA works in close partnership with the EverCare Nurse Practitioners, collaborating physician, RN Case Manager (RNCM), and Triage team, providing both field-based clinical support during facility visit days and office-based clinical and administrative support. Core responsibilities include pre-visit chart preparation, administration of standardized geriatric screening instruments, care coordination with facilities and community providers, structured call intake and follow-up, medication and prior-authorization processing, and documentation support for value-based care programs including the Annual Wellness Visit (AWV), Chronic Care Management (CCM), Transitional Care Management (TCM), and quality measure reporting. Because EverCare operates a lean, team-based staffing model, the MA may also assume selected functions otherwise assigned to the RNCM in EverCare workflow documents, when those functions fall within the MA scope of practice and are appropriately delegated and supervised by a licensed provider in accordance with the Michigan Public Health Code. All clinical tasks are performed under the delegation and supervision of an EverCare licensed provider; the MA does not perform independent nursing assessment, clinical triage, or medical decision-making.

Essential Functions:

Visit Support and Direct Patient Care

1. Administers and scores standardized geriatric screening instruments as delegated and per protocol (e.g., Mini-Cog, PHQ-2/PHQ-9, falls risk/STEADI, nutrition, hearing/vision, health risk assessment, and SDOH screening), documenting results in the EMR for provider review and interpretation.
2. Performs CLIA-waived point-of-care testing per practice protocol and specimen collection (including phlebotomy, if competency-verified), and coordinates with contracted mobile phlebotomy and mobile imaging vendors for orders the practice does not perform directly.
3. Completes AWV supporting components as delegated (health risk assessment administration, screening documentation, preventive services review preparation) for provider completion of the visit.
4. Prepares charts prior to initial and follow up visits by reviewing insurance, prior visit notes, reviewing and updating chart with additional health information such as post-hospital discharge summaries, ER summaries, consultation notes, labs and imaging.

Pre-Visit Preparation and Care Coordination

1. Owns pre-visit chart preparation for scheduled visits per EverCare workflow standards: assembles outside records, recent utilization, current facility medication administration records, pending results, and screening due lists; signals chart readiness to the provider via EMR task no later than 48 hours before the visit; and escalates incomplete critical items at morning huddle.
2. Builds and maintains the initial chart at referral receipt, including demographics, facility and room information, insurance verification, DPOA/healthcare-proxy documentation, POLST/advance directive upload, and preferred family/caregiver contacts.
3. Obtains and shares clinical information with hospitals, skilled nursing facilities, ALF/AFC staff, primary and specialty community providers, and ancillary services to support continuity of care; utilizes the Health Information Exchange (HIE) and ADT alerts to support transitions of care.
4. Supports the TCM workflow as delegated: monitors discharge alerts, requests discharge documentation, schedules TCM visits within the required 7- or 14-day windows, and documents outreach in the TCM tracker.

Communication and Follow-Up

1. Receives incoming calls from patients, families, and facility staff; gathers structured information per practice protocol; routes clinical concerns to the Triage RN, RNCM, or provider per the message-routing matrix; and never performs independent telephone triage or gives clinical advice beyond approved, provider-directed instructions.
2. Completes follow-up tasks after patient visits and triage encounters as directed by the NP or physician, including callbacks, appointment scheduling, and confirmation that orders were received by facilities, pharmacies, and vendors.
3. Communicates patient status updates to referral sources and facility partners, supporting EverCare’s facility relationships and census growth.

Orders, Documentation, and Value-Based Care Support

1. Processes medication and treatment orders through the electronic prescribing system as directed by providers; manages insurance prior authorizations for medications, imaging, and services.
2. Retrieves laboratory and imaging results and routes them promptly to the ordering provider; completes provider-directed result notifications to patients, families, and facilities.
3. Ensures consents (including CCM enrollment consent) and required medical documentation are accurately completed, obtained, and stored in the EMR; supports CCM time-and-activity documentation in accordance with practice protocol.
4. Supports quality measure gap closure and accurate, complete documentation that enables provider capture of chronic conditions consistent with the practice’s value-based care and risk-adjustment documentation standards.
5. Maintains accurate and up-to-date electronic medical records (EMR) for all assigned patients.

Team, Compliance, and Organizational Expectations

1. Participates in daily huddles and interdisciplinary team meetings; provides coverage support for other EverCare clinical support staff during PTO or other leaves.
2. Performs additional delegated functions otherwise assigned to the RN Case Manager in EverCare workflow documents when within the MA scope of practice, appropriately delegated by a licensed provider, and supported by documented competency validation.
3. Attends department and agency-wide meetings as assigned.
4. Demonstrates a strong understanding of and commitment to EverCare’s model of geriatric, value-based primary care and the mission and vision of the agency.
5. Ensures compliance with all applicable local, state, and federal regulations — including Michigan delegation and scope-of-practice requirements, CLIA, and HIPAA — as well as agency policies and quality standards.
6. Adheres to the organizational Code of Conduct and all departmental and organizational policies, procedures, protocols, practices, and all regulatory and legal requirements.
7. Adheres to the NorthStar standards to care for every person, every time, 100% of the time.

Qualifications:

1. Certified or Registered Medical Assistant (CMA or RMA) required, with a solid understanding of medical terminology, clinical documentation, and healthcare regulations, including medical law and ethics and the delegated scope of the MA role in Michigan.
2. Minimum of two (2) years of clinical medical office experience required; primary care, internal medicine, or geriatrics experience strongly preferred.
3. Prior experience with older adults in long-term care, assisted living, home-based, hospice, or palliative care settings strongly preferred; comfort working independently in residential facility environments is essential.
4. Current BLS certification required (or obtained within ninety (90) days of hire).
5. Phlebotomy and CLIA-waived point-of-care testing competency preferred; competency validation required prior to performing these functions.
6. Familiarity with the needs of frail, medically complex, and cognitively impaired older adults, including sensitivity to physical, emotional, and psychosocial needs of patients and their families; ability to provide compassionate support and maintain professionalism in emotionally complex situations is essential.
7. Proficient in the use of electronic medical records (EMR), multi-line phone systems, and standard office equipment; experience with athenahealth and Health Information Exchange platforms is a plus.
8. Working knowledge of Medicare preventive and care-management services (AWV, CCM, TCM, advance care planning) and value-based care documentation practices preferred; willingness to learn required.
9. Accurate and efficient keyboarding and data entry skills.
10. Proof of current tuberculin testing required. Patient/facility contact will not be allowed until tuberculin clearance is documented.
11. Must be able to read, write, and speak English fluently and be able to effectively communicate orally and in writing in internal and external relationships for all essential job functions.
12. Must possess sound judgment and demonstrate strong critical thinking skills and the ability to function under stress. Must demonstrate ability to maintain accountability and work independently while functioning as part of a cooperative, coordinated team, and to recognize and escalate matters outside the MA scope of practice.
13. Demonstrated ability to organize, prioritize, and manage multiple competing priorities with great attention to detail, accuracy, tact, and the ability to maintain confidential information.
14. The physical demands of the position include: vision, effective speech, and hearing for extensive telephone contact; repetitive motion; traveling between facilities; driving or riding in a motor vehicle for extended periods; standing, sitting, walking, bending, reaching, and stretching; lifting up to forty-five (45) pounds unassisted and the ability to assist in transferring or repositioning patients using appropriate techniques and/or devices.
15. Must have a valid driver’s license, reliable transportation, and proof of automobile insurance; daily travel to assisted living and adult foster care facilities within the service area is required.
16. Must have the ability to occasionally work extended days, as necessary.
17. Must be eligible to work in the United States.

This description is intended to indicate the kinds of tasks and levels of work required of the position. It is not intended to limit the assignment of other duties. Delegated clinical functions are subject to Michigan delegation requirements, documented competency validation, and practice protocols, and may be modified as the EverCare staffing model evolves.