# # # # # # The CMA Care Coordinator is responsible for helping to coordinate the organization#s clinical care management and Primary Care activities, including care transitions activities to help improve the care outcomes for eligible at-risk patients. Our goal is to enhance the patient experience, improve quality and reduce costs for a patient#s care and care transitions. Responsible for supporting primary and specialty care objectives in outreach to our patients, coordination of care with managers, and proactively creating relationships with providers and patients to ensure optimal health and wellness for our patient population. C ertified Medical Assistant from an accredited vocational institution of community college to indicate completion of a course in medical assisting. Minimum 1 year of experience working in a medical facility as a medical assistant and/or documented evidence of externship completed in a medical office. Knowledge of healthcare field. Excellent communication and interpersonal skills necessary for interacting with patients, physicians, care team members and leadership. Ability to organize and accomplish multiple tasks and to have the flexibility to meet changing demands on a daily basis. Organizational and critical thinking skills and ability to prioritize workload and maintain a flexible problem solving approach. Knowledge of community resources preferred. Ability to project a pleasant and professional image even under stressful situations. Ability to maintain confidentiality. Must complete most duties with minimum direct supervision. Some experience with Microsoft Office suite; knowledge of EPIC electronic medical record system preferred. Knowledgeable in use of general office equipment including computer and typing skills. # # # # certification preferred. Coordination of Care # Facilitation of Safe Patient Transitions E (Annual Only) #EE# #SA# #PA# #RD #N/A Serve as the liaison and point of contact regarding patient transitions from the inpatient, observation or ED setting back to the outpatient setting in order to coordinate appropriate post-discharge care. Identify patients eligible for a care transitions intervention using available EPIC reports. Review patient discharge instructions and facilitate discussions with active members of the care team, as appropriate, to understand and facilitate patient care needs and/or resource gaps. Identify resource gaps and coordinate and/or facilitate connections to needed services so as to remove barriers to care and to ensure patients are able to access services efficiently. C ontact each patient to coordinate follow up care, future appointments, review and reconcile new medications and medication changes, check on general health since discharge, and answer questions from the patient. Effectively coordinate service requirements and connection of patients to appropriate organization, system or community resources. C onsult PC P or designee for guidance as indicated. Ensure effective communication in a secondary language, or obtain an interpreter, as needed. Proactively identify, report and resolve potential or actual patient safety issues as needed or as directed. #
Associated topics: care, clinic, family medicine, family practice physician, nocturnist, physician, physician md, physician md do, primary, urgent
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