In collaboration with care teams, staff and families, the Medical Assistant, Care Coordinator - Permanent Supportive Housing (PSH) is responsible for coordinating and managing patient care to ensure the highest quality care and patient experience. The Medical Assistant, Care Coordinator - PSH works in collaboration with patients, families (as defined by the patient), and staff across program-specific disciplines and departments to provide care and resource information for patients enrolled in the permanent supportive housing collaborative or receiving services at CommUnityCare, meeting with patients in their homes, community spaces, or in the health center setting.

Permanent Supportive Housing (PSH) is permanent housing in which housing assistance (e.g., long-term leasing or rental assistance) and supportive services are provided to assist households with at least one member (adult or child) with a disability in achieving housing stability.

Essential Duties:

• Interacts with patients via phone calls, medical, or social services appointments, in their home in collaboration with another team member, community spaces on PSH properties, and other locations per program guidelines, to bridge the gap between systems.
• Serve as a point of contact for patients enrolling in PSH Health Care Collaborative.
• Collaborates with PSH Health Care Collaborative partners, including Integral Care, Central Health, and ECHO on patient-centered care.
• Coordinate preventative, wellness, and chronic needs management services using evidenced based practice and care models.
• Provide comprehensive care to increase patient and family perception of quality care.
• Improve communication between patient and health care providers.
• Support patients using a comprehensive, care management model of care.
• Increase patient’s knowledge of medical conditions and improve self-management practices.
• Coordinate with internal and external social services agencies and programs to ensure that patient receives needed services.
• Support patients to increase medical compliance, improve health outcomes, and increase their self-report quality of life.
• Empower patients and/or their families to be an engaged, active participant in their care management.
• Complete all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
• Attend daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the clinic.
• Attend seminars and maintain all licensure and/or certification requirements for continuing education and best practices.
• Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
• Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
• Complete other duties as assigned

Knowledge/Skills/Abilities:

• High level of skill at building relationships and providing excellent customer service.
• Requisite skills and ability to perform certain medical tasks as assigned.
• Strong attention to detail and accuracy.
• Ability to utilize computers for data entry and information retrieval.
• Excellent verbal and written communication skills.

MINIMUM EDUCATION:

• Graduation from high school or equivalent.
• Medical Assistant Diploma

MINIMUM EXPERIENCE:

• 2 years of clinical Medical Assistant experience 

LICENSES/CERTIFICATIONS:

• Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current CPR certification during employment