Job Overview:This position is responsible for providing direct patient care in a primary care office. This position will maximize synergy between care delivery providers to identify gaps in care, contact patients to schedule required care, and provide referral follow up. The successful Medical Home Medical Assistant will provide pre-visit planning for the practice's patient panel, coordinate messages through electronic portals, and assist in managing care transitions into and our of the office. The Medical Home Medical Assistant will act as a clinical liaison to the physician care plan and will actively communicate with patients. The Medical Assistant will suggest process improvements, understand clinical goals (including TPEC Q1), and shall work to manage patient satisfaction and engagement. Must have competency in clinical care, customer service communication, and team work. Must be certified or register medical assistant. must maintain certified or registered status.Job Requirements:Graduate of an approved technical, professional, or vocational program in Healthcare; Healthcare clinical experience preferred physician practice or related fieldEquivalent experience accepted in lieu of degreeMust be certified or registered medical assistantMust maintain this certification and registration status Registered Medical Assistant (RMA), through AMT, NCCT, or NHA, or certified Medical Assistant (CAN) by AAMA, and Cardiopulmonary Resuscitation (CPR)Medical office flow, especially the clerical/front office tasksAbility to make quick decisions based on well thought out consequences/resultsKnowledge of EMR, practice management software and medical coding/billing strongly encouraged3-4 years experience Clinical HealthcareJob Responsibilities:Provides expertise in the primary care rooming process, relevant medical procedures, and adult and pediatric patient care. Follows protocols and policies for clinical procedures and appropriate use of medical equipment. Follows scheduling decision trees and clinical protocols to assure appropriate patient access and disposition. Provides accurate and complete documentation of clinical calls, and all facets of the patient's care. Addresses patient messages in a timely manner and escalates patient issues as appropriate. Utilizes and monitors MyChart messaging to support patient communication.Participates as a part of the patient centered medical home team during all patient visits by reviewing the patient chart of clinical gaps in care. Assists with outreach campaigns and tactics to close gaps in care. Supports and completes pre-visit planning, and participates in daily huddles with the physician and care team. Embraces the philosophy of wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year. Informs physician of any potential barrier identified by the patient.Utilizes knowledge of population health and value based contracts. Works from knowledge of key quality and unitization metrics of value-based programs for both wellness and chronic disease management. Has proficient understanding of the Primary Care quality program including all protocols of well and chronic disease states. Can identify patients "at risk" for change in condition and increased utilization. Attends required population health training and education such as Lunch and Learns and other opportunitiesParticipates in the longitudinal care continuum of patients through completing post ED/post inpatient discharge outreach on identified risk patient group. Updates care team thorough documentation and works collaboratively with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist. Knowledgeable and able to provide basic community resources to patients with social determinates in health. Supports and provides education and patient coaching of both wellness and chronic disease management. Supports