The Clinical Care Partner is responsible for coordinating patient care appointments, following established standards and practices of population health management, calls patients for follow-up appointments who were recently admitted to the hospital. Calls patients that are identified by the Quality Department as high risk or need an appointment to address Quality measures. Relies on guidelines to accomplish tasks. Relies on experience to complete job. Works under close supervision of Clinic Manager and Quality Manager.

• Coordination of Care
• Reviews evidenced based care measures for population of patients, assists providers with quality measures to ensure the care needs are outlined and established prior to visit optimizing patients time with the Provider.
• Prepares for clinic interdisciplinary team meetings/huddles by confirm previous orders have been completed and resulted, review inpatient admissions, review anticipated annual screenings, prepare agenda for meetings, print patient care summary for providers as needed, identify high risk patients and communicate with team for follow up.
• Call and schedule patients listed on Quality Gap report and meet specified deadline.Request results from outside facilities and scan results into patient EMR by established deadlines.
• Observes and adheres to quality standards established by the department. Participates in continuous quality improvement programs in order to foster the provision of quality health care services by the department and clinic to ensure all services are provided with compassion, understanding, and respect for others.
• Conduct post visit review on clinic wellness patients as well as specific measures with Population (Adult and Pediatric) such as uncontrolled blood pressure, etc.
• Other Duties as Assigned
• Performs other duties as assigned or requested.

Experience - 3 years experience as a medical assistant
Education - Graduate of an accredited medical assistant program, or 2 years additional medical assistant experience in lieu of education.
License - BLS Certification

• Coordination of Care
• Reviews evidenced based care measures for population of patients, assists providers with quality measures to ensure the care needs are outlined and established prior to visit optimizing patients time with the Provider.
• Prepares for clinic interdisciplinary team meetings/huddles by confirm previous orders have been completed and resulted, review inpatient admissions, review anticipated annual screenings, prepare agenda for meetings, print patient care summary for providers as needed, identify high risk patients and communicate with team for follow up.
• Call and schedule patients listed on Quality Gap report and meet specified deadline.Request results from outside facilities and scan results into patient EMR by established deadlines.
• Observes and adheres to quality standards established by the department. Participates in continuous quality improvement programs in order to foster the provision of quality health care services by the department and clinic to ensure all services are provided with compassion, understanding, and respect for others.
• Conduct post visit review on clinic wellness patients as well as specific measures with Population (Adult and Pediatric) such as uncontrolled blood pressure, etc.
• Other Duties as Assigned
• Performs other duties as assigned or requested