Medical Assistant

The Medical Assistant (MA) will serve as the Care Management Program Coordinator, overseeing and executing the practice’s Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) programs.

This role bridges clinical and administrative functions, supporting physicians and mid-level providers in delivering proactive, high-quality, and compliant virtual care for patients with chronic conditions.

The MA will monitor patients enrolled in care management programs, ensure timely outreach and documentation, and drive measurable improvements in patient engagement, quality metrics, and revenue performance.

Reports To Practice Manager / Lead Physician / Director of Clinical Operations

• Competitive pay and benefits package.
• Opportunity to work in a supportive and collaborative team environment.
• Training and growth opportunities within the clinic.
• Paid time off and holidays (for full-time employees).
• Coordinate and manage daily workflows for RPM, CCM, PCM, and APCM programs across assigned providers or departments.
• Identify eligible patients through EMR reports and ensure proper enrollment and consent documentation.
• Perform patient onboarding for RPM devices, education, and troubleshooting.
• Track patient adherence, vitals, and alerts through the remote monitoring platform.
• Conduct monthly CCM calls per CMS guidelines, documenting clinical status, interventions, and care coordination activities.
• Escalate clinically significant findings to supervising providers in real-time.

• Support physicians and mid-levels in chronic disease management (HTN, CHF, DM, COPD, CKD, etc.).
• Record and maintain accurate patient notes, vitals, and care plans in the EMR.
• Coordinate medication refills, lab orders, and specialist referrals as part of ongoing care management.
• Assist with Annual Wellness Visits (AWVs) and Quality Measure tracking.
• Prepare monthly reports summarizing patient engagement, outcomes, and billing opportunities.
• Ensure documentation meets CMS time and content requirements
• Collaborate with the billing and RCM teams to verify claim submission accuracy.
• Maintain HIPAA compliance and patient confidentiality at all times.
• Serve as the main point of contact for enrolled patients - providing education, motivation, and support.
• Coordinate with care teams to close gaps in care and improve HEDIS / quality scores.
• Support social determinants of health screening and referrals as needed.
• Foster a patient-centered approach through empathy, clear communication, and proactive follow-up.

• Certified or Registered Medical Assistant (CMA, RMA, CCMA, NCMA) required.
• Additional certification in Chronic Care Management or Telehealth preferred (training can be provided).

• Minimum 2 years of outpatient clinical experience, preferably in primary care or a chronic disease specialty (Cardiology, Endocrinology, Pulmonology, Rheumatology).
• Prior experience with care coordination, telehealth, or population health management strongly preferred.
• Familiarity with EMR systems (eCW, Athena, Epic, etc.) and RPM platforms (e.g., Validic, Coach Care, iHealth, etc.) a plus.

• Strong clinical judgment and ability to triage patient data.
• Excellent organizational and communication skills.
• Comfort with technology, remote monitoring tools, and EMR workflows.
• Ability to multitask and manage a panel of 300-500 patients.
• Team player with a proactive, ownership mindset.