Medical Assistant- Care Management

Job Summary: The intent of this job description is to provide a summary of the major duties and responsibilities performed in this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description. The Care Management Medical Assistant plays a key role in supporting Rancho Health’s Chronic Care Management (CCM) programs and other care coordination initiatives. This position serves as a vital link between patients, providers, and care teams—helping manage transitions of care, maintain up-to-date care plans, and ensure patients receive the support they need to follow their health plans effectively. This role is primarily conducted over the phone and electronically, supporting a variety of administrative and clinical coordination tasks. Essential Job Duties: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Chronic Care Support & Coordination: Provide monthly outreach and support to patients enrolled in CCM programs, ensuring 20+ minutes of engagement as required for Medicare billing. Maintain and update patient care plans annually or as clinical status changes. Review and summarize hospital, specialist, and ER notes; request relevant medical records and upload into EMR. Confirm patients are attending provider appointments and adhering to their care plans; identify and address barriers to care. Administrative & Clinical Workflow Support: Schedule and manage appointments, including follow-ups post-hospitalization. Process medication refill requests, particularly after inpatient or ER admissions, following standing protocols. Coordinate referrals and prior authorizations for medications, procedures, or specialist services. Handle incoming phone calls, inbox tasks, and faxes—ensuring timely response and accurate documentation. Documentation & Communication: Execute standing orders and assist with triage communication under RN or provider guidance. Ensure all patient communications and documentation are promptly and accurately reflected in the EMR. Maintain internal spreadsheets to track CCM time spent and support billing accuracy. Required education and experience: The requirements listed below are representative of the knowledge, skills, and/or ability required. Minimum Education (or substitute experience) required: High School Diploma or equivalent (GED). A Medical Assistant diploma or certificate of completion from a medical assistant training program is required. Current Basic Life Support (BLS) Certification/CPR certification preferred. Minimum Experience: 2+ years of experience in working with Primary Care, Urgent Care, Internal Medicine, Pediatrics, Women’s Health, Geriatrics a plus. Minimum Knowledge and Skills Required: Bilingual Spanish is preferred. Knowledge of medical terminology. Understanding principles and practices of the organization, planning, records management, and general administration. Dependability, adaptability, and confidentiality are necessary attributes. Knowledge of accepted procedures for disposing of used supplies. Ability to communicate effectively and congenially with patients and staff members virtually, via email and over the phone. Ability to exercise tact, initiative, and good judgement when interacting with patients and staff members. Ability to observe the general physical condition of patients to detect signs of abnormalities. Ability to record observations and notes completely, accurately, literately, and concisely. Computer skills are necessary to navigate the company’s EMR system. Ability to accept supervision and feedback. Mon - Fri (hours based on company needs)