Medical Assistant Care Coordinator (DHWC)

Position Summary

Medical Assistant Care Coordination supports the patient-centered medical home (PCMH) model by working closely with Care Coordination RN/LVN and the integrated care team.

This role focuses on patient engagement, care coordination, follow-up support, and health outcomes improvement in both clinic and home settings.

Scope and Impact

This position directly impacts patient care continuity, outcomes, and experience by supporting clinical workflows, coordinating referrals, monitoring patient needs, and improving access to care.

While the role has no direct budgetary or supervisory responsibility, it significantly influences patient satisfaction and clinical effectiveness across assigned patient populations.

Decision-Making Authority

Operates under established protocols and supervision.

Uses judgment in monitoring patients, escalating clinical concerns, and coordinating care.

Exercises discretion in prioritizing tasks and responding to patient needs in clinic and home visit settings.

Interactions / Working Relationships



* Internal: Daily collaboration with Care Coordination RN/LVN, primary careproviders, Wesley Nurses, Clinical CHWs, and clinic staff.


* External: Frequent interaction with patients and families, specialists, hospitals, and community agencies.

May engage with external agencies for welfare checks.

Essential Duties and Responsibilities



* Collaborate with Care Coordination RN/LVN and healthcare team to promote PCMH principles and seamless care.

20%)


* Coordinate follow-up care after ER visits, including scheduling appointments, assisting with medication needs, and specialty referrals.

(15%)


* Provide education and navigation support to patients and families regarding ongoing care and conditions.

(15%)


* Conduct home visits to assess patient needs, support care plans, and promote health outcomes.

(10%)


* Monitor and respond to changes in patient condition in-person, by phone, or during home visits.

(10%)


* Assist with transition of care to ensure continuity between healthcare settings.

(10%)


* Respond to patient inquiries, complaints, and requests; provide resolution or escalate as appropriate.

(10%)


* Occasionally take and document vital signs both in clinic and home settings.

(5%)


* Document patient outcomes using accurate clinical terminology.

(5%)


* Perform other duties as assigned to support the integrated care team and patient population.

Supervisory or Leadership Responsibilities

This position does not supervise others.

Qualifications

Minimum Qualifications (Required)



* Education: High school diploma or GED; graduation from an accredited Medical Assistant program.


* Licenses/Certifications:
+ Currently registered with the Texas Department of Aging and Disability Services, National Association for Health Care Professionals, or National Healthcare Association.
+ Current BCLS certification.


* Experience: Minimum...