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.