Job Overview: This position provides both direct patient care in a primary care office and works with care delivery providers to identify gaps in care, contacts patients to schedule required care, and provides referral follow up. The Medical Home Medical Assistant provides pre-visit planning for the practice's patient panel, coordinates messages through electronic portals, and assists in managing transitions of care. The Medical Home Medical Assistant will act as a clinical liaison to the physician care plan and actively communicate with patients. The MA participates in process improvements, is knowledgeable of clinical goals and outcomes including patient satisfaction and engagement. Other job-related duties may be assigned to meet the needs of the department. Must be certified or registered medical assistant and have strong skills in clinical care, customer service, communication, and teamwork. This role understands the needs of the organization and supports the mission, values, and management of TriHealth Physician Practices. Job Requirements: Graduate of an approved technical, professional, or vocational program in Healthcare; Healthcare clinical experience preferred physician practice or related field Equivalent experience accepted in lieu of degree Must be certified or registered medical assistant Must maintain this certification and registration status Registered Medical Assistant (RMA), through AMT, NCCT, or NHA, or certified Medical Assistant (CAN) by AAMA, and Cardiopulmonary Resuscitation (CPR) Medical office flow, especially the clerical/front office tasks Ability to make quick decisions based on well thought out consequences/results Knowledge of EMR, practice management software and medical coding/billing strongly encouraged Job Responsibilities: Demonstrates proficiency in the rooming process for adult and/or pediatric primary care including: clinical procedures, immunizations, venipuncture, point of care testing, among others. Follows protocols and policies for scheduling, clinical procedures and appropriate use of medical equipment. Provides accurate/complete documentation of clinical calls and patient rooming info as well as order entry, pending prescriptions, noting current pharmacy, and enter edit workflows to result orders. Addresses patient messages (phone, mychart) in a timely manner and escalates patient issues as appropriate. Demonstrates clinical competency upon completion of orientation and annually. Maintains knowledge of population health, and embraces the philosophies of wellness, prevention and chronic disease management. Participates in tactics to close gaps in care. This includes pre-visit planning, participation in daily huddles, and informing physicians of any potential barriers to care identified. Has proficient understanding of the adult and/or pediatric preventative medicine schedule, which includes age-based wellness checks, appropriate vitals and labs, immunizations to administer, screening tools, and patient education to care for all patients we serve. Can identify and communicate with providers regarding patient wellness, chronic diseases, utilization, and care gaps. Attends continued education training and education such as Lunch and Learns and other opportunities. Participates in the longitudinal care continuum of patients. This includes collaborating with wrap-around services such as behavioral health, complex care nursing, social workers, community health workers, among others. Provides basic community resources to patients with social determinants of health. Supports and provides education and patient coaching of both wellness and chronic disease management. Other Job-Related Information: Demonstrates knowledge in area of practice such as: Age related competencies and care of various populations. Understanding best practices in preventative care, chronic disease management and utilization across the continu