Certified Medical Assistant

TRANSITIONAL CARE MANAGEMENT JOB DESCRIPTION General Summary of Duties: To provide best practices for Transitional Care Management (TCM) for outreach and enabling services for the SICHC (Southern Indiana Community Health Care, Inc.) organization. Overview: The position provides professional assistance to SICHC in managing outreach and enabling services under the general direction and supervision of the Enabling Services Manager, Department Lead, the Office Manager and/or the CEO (Chief Executive Officer). Primary Duties and Responsibilities: • Maintain TCM protocols per CMS (Centers for Medicare & Medicaid Services) rules. • Contact patients that have been discharged from a hospital or Skilled Nursing Facility within 2- business days of discharge. • Review Hospital discharge records and discuss hospital stay with patient. • Medication Reconciliation done on every patient, including new meds from hospital discharge, and confirming all medications. • Prepare the EMR (Electronic Medical Record) chart note for the provider to use during the TOC (Transition of Care) office visit. • Schedule patients within the 7 – 14-day guidelines according to acuity level. • Link patients with needed resources such as: Chronic Care Management; Community Health Worker; More than Money; CHAP Program; Navigator, etc. • Provide patient education based on Hospital discharge diagnosis. • Collect and enter accurate data on all patients; produce accurate and timely reports as requested. • Fill out and answer Questionnaires: PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks and Experiences); SDOH (Social Determinants of Health), or other assigned assessment tools. • Participate in webinars, conferences and other SICHC approved training to improve knowledge and skills related to the job. • Maintain a high level of ethical conduct regarding confidentiality and professionalism. • Demonstrate competent use of EMR. Primary Duties and Responsibilities(continued): • Timely completion of paperwork and documentation. • Requires basic organizational skills, typically to organize own work. • Work independently or as part of a team. • Effectively select from alternatives to situations encountered on the job. • Focus primarily on TCM. • Assist Chronic Care Manager with duties as needed. • Attend morning Huddles to plan days' work. • All other duties as assigned pertaining to the job. • Cross-coverage in CMA duties may be needed; therefore, requires maintaining EMR proficiency. • Answer questions or concerns related to TCM (support staff and providers). Performance Requirement Knowledge, Skills, and Abilities: • Requires current Certificate as Medical Assistant (at a minimum). • Technically proficient computer skills with Microsoft Office Suite (Work, Excel, PowerPoint). • Thorough knowledge of common office equipment (copier, fax, printer, scanner, etc.). • Excellent oral and written communication skills. • Ability to organize and prioritize tasks. • Ability to work under pressure and meet deadlines. • Strong analytical, attention to detail, and problem-solving skills. • Ability to work independently and as a team member. • Ability to establish and maintain effective working relationships with patients, employees, and the public. • Clear diction and acute hearing are necessary for effective communication with the staff and public. Physical Demands/Working Conditions: General office/clinic conditions are pleasant; good, clean working conditions where accidents and hazards are negligible; requires short periods of moderate lifting, stooping, bending, stretching, pushing, pulling, and carrying objects up to twenty pounds.