Advanced Medical Assistant - MDPCP

 Position Objective:Advanced Medical Assistant 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.  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. Essential Job Duties:Monitor and validate patient attribution to the practice and the care teams within the practice (known as empanelment).Ensure patients identified as increased risk receive targeted, proactive, relationship-based (longitudinal) care coordination and/or care management.Pre-visit planning workflow for Annual Wellness Visits scheduled with the LPN Team and/or practice provider.Provide patient education and resources to engage the patient in his/her treatment plan and improve their overall health.Actively 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.Maintains access to all Value Based Payor portals for attestation of metrics and/or to pull appropriate care gap and utilization reports.Provides patient outreach for TCM/ED visits within required timeframe, i.e. within 48 hours inpatient discharge; within 7 days emergency room discharge.  The Advanced Medical Assistant will schedule a follow up appointment with the patients primary care provider or Advanced Internal Medicine.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;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.Identify patient social and behavioral health needs, consult with clinician, as appropriate provide warm hand off to Ambulatory Care Management, social work, care navigation, and behavioral health services.Collaborate with providers, and other frequently used healthcare resources to develop effective timely communication between the patients care teams; and in assessing the patients progress toward individual health ca...