Advanced Medical Assistant- MDPCP

<p>&nbsp;</p><p><strong>Position Objective:</strong></p><p><strong>Advanced Medical Assistant </strong></p><p>The Advanced Medical Assistant is an essential part of the Advanced Primary Care Team and facilitates meeting the goals of the Maryland Primary Care Program and Value Based Contracts.&nbsp; Their main responsibilities are to coordinate patient care, provide patient outreach and education and identify barriers that may affect the patient from meeting his/her treatment goals. The Advanced Medical Assistant will perform a variety of administrative and clinical tasks to support the provider/practice to ensure the patient receives the right care at the right time and right place to decrease hospital re-admission and unnecessary utilization of Emergency Room and/or Urgent Care. The Advanced Medical Assistant maintains knowledge of care coordination/management, behavioral health resources, CRISP Portal/Reports, Value Based Contract Portals, EPIC Registries and patient self-management tools/resources.<br> <strong>Essential Job Duties:</strong></p><ol><li>Monitor and validate patient attribution to the practice and the care teams within the practice (known as empanelment).</li><li>Ensure patients identified as increased risk receive targeted, proactive, relationship-based (longitudinal) care coordination and/or care management.</li><li>Pre-visit planning workflow for Annual Wellness Visits scheduled with the LPN Team and/or practice provider.</li><li>Provide patient education and resources to engage the patient in his/her treatment plan and improve their overall health.</li><li>Actively&nbsp;manages assigned panel of to develop relationship with patient as an integral member of team, provide follow-up contact with patient as indicated to ensure compliance with recommendations medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.</li><li>Maintains access to all Value Based Payor portals for attestation of metrics and/or to pull appropriate care gap and utilization reports.</li><li>Provides patient outreach for TCM/ED visits within required timeframe, i.e. within 48 hours inpatient discharge; within 7 days emergency room discharge.&nbsp; The Advanced Medical Assistant will schedule a follow up appointment with the patients primary care provider or Advanced Internal Medicine.</li><li>Assist patients in setting SMART goals for self -management, teaching them how to do self-management tasks and report abnormal findings to their provider team;</li><li>Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments; refers patient to the Community Care Management Team (RN, LCSW, CHW) for intervention.</li><li>Identify patient social and