- Patient outreach and monitoring by conducting monthly telephonic or digital check-ins (typically 20+ minutes) to monitor health status and adherence to care plans.
- Identifies program eligibility
- Performs medication reconciliation and verify compliance, ensuring patients understand their prescriptions and identifying potential drug interactions.
- Schedule follow-up appointments, facilitate specialist referrals, and coordinate community resources like transportation or home care.
- Follows up with preventative screenings.
- Support patients during transitions of care, such as follow-up after a hospital discharge or ER visit.
- Provides effective clinical health coaching to assist the patients with self-management of their chronic disease and life-style changes to mitigate health risks.
Education: High School Diploma/GED required, Vocational/Technical degree as Medical Assistant or Related field required.
Certification/License: Certified Medical Assistant (CMA) required. CPR preferred.
Experience: At least 1 year experience as MA in a Clinic/Office is preferred. Strong understanding of chronic conditions (diabetes, heart disease, CHF) and medical terminology. Excellent phone etiquette, active listening, and the ability to explain complex medical information in simple terms. Proficiency with EHR systems and Microsoft Office applications. Empathy, strong organizational skills, and the ability to work independently in a fast-paced or remote environment.
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Monday- Friday 8:00- 4:30
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