Medical Assistant Care Coordinator (DHWC)

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.

• 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.

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 of one (1) year in a clinical setting.
• Other Required Skills/Knowledge: Must have a valid driver's license, access to a reliable vehicle, and current auto liability insurance. Bilingual fluency in English and Spanish required.

• Experience with electronic health records (EHR).
• Previous experience in community health or with vulnerable populations.
• Experience coordinating care across multiple providers or health systems.
• Additional certifications in community health or care coordination.

• Strong collaboration and teamwork skills.
• Effective verbal and written communication skills.
• Cultural sensitivity and ability to provide patient-centered care.
• Problem-solving and decision-making in clinical environments.
• Adaptability and initiative in dynamic patient care settings.
• Ability to work independently with minimal supervision.

• Required: Fluency in English and Spanish (bilingual proficiency is mandatory).
• Must be able to provide verbal interpretation between providers and patients.

• Required: Basic proficiency with Microsoft Office (Outlook, Word, PowerPoint, Excel) and internet usage.
• Preferred: Experience using Electronic Health Record (EHR) systems.

• Setting: Primarily clinic-based with frequent field and home visits.
• Travel: Local travel required; must have reliable transportation.
• Physical Requirements:
• Frequent standing, sitting, walking, bending, stooping, reaching, kneeling, crouching, and twisting. Must be able to lift and maneuver up to 25 pounds.
• Use of step stools and ability to navigate patient homes safely.