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Transition of Care Medical Assistant - Phoenix, AZ

Job Details

Job Location

Adelante Healthcare Center Support Office - Phoenix, AZ

Description

POSITION SUMMARY

The Transition of Care (TOC) Medical Assistant serves as a vital administrative liaison between Adelante Healthcare and patients requiring Transition of Care services. As the initial point of contact for patients transitioning from hospital or acute care settings, this role ensures that each patient’s care is coordinated, timely, and supportive of a safe and effective recovery.

Key responsibilities include running and reviewing TOC reports, obtaining and filtering medical records to determine TOC eligibility, and ensuring all relevant documentation is accurately uploaded into the Electronic Health Record (EHR) system. The TOC Medical Assistant is also responsible for contacting patients to schedule timely TOC follow-up appointments with their medical and behavioral health providers and facilitating warm hand-offs to TOC Registered Nurses.

Working within their defined scope of practice, this individual collaborates closely with the TOC nursing team to support seamless care coordination. The role requires strong attention to detail, excellent communication skills, and the ability to manage clinical data with accuracy and efficiency.

The TOC Medical Assistant plays a critical role in Adelante Healthcare’s patient-centered, team-based medical home model by helping to ensure continuity of care, reduce hospital readmissions, and improve health outcomes for patients in transition.

EXPECTATIONS

Every Adelante Healthcare employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected to work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism, and competence.

OUR CORE VALUES

+ I nclusion

+ N urture

+ S ervice

+ P urposeful

+ I ntegrity

+ R esilient

+ E ngaged

Qualifications

ESSENTIAL SKILLS AND EXPERIENCE

+ High School Diploma

+ Graduation from an accredited medical assistant program (preferred) or certificate in a healthcare-related field .

+ Minimum of two (2) years' experience in a healthcare setting .

+ Experience working with electronic healthcare records (E.H.R.), navigating the system to complete audits .

+ Knowledge of regulatory agency requirements, including Joint Commission, HRSA, and AZDHS.

+ Ability to maintain confidentiality, privacy, and security of protected information.

+ Excellent working knowledge of Microsoft Office Applications, including Outlook, Word, Excel, Teams, and SharePoint.

+ Knowledge of SBAR and clear communication.

+ Ability to travel to health center locations .

+ Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and the Red Cross (cognitive and skills evaluations) .

+ Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations or ability to obtain within 30 days of employment.

+ Competency in working with people of various cultures.

+ Preferred Bilingual (Spanish/English)

+ Excellent customer service and communication skills

+ Ability to communicate effectively both orally and in writing

+ Meet the organization’s immunization requirements

+ Valid Arizona driver’s license

POSITION RESPONSIBILITIES

Administrative Responsibilities

+ Produce Transition of Care (TOC) reports to track patient progress and outcomes.

+ Screen and filter reports to determine TOC eligibility for patients.

+ Review patient charts using Electronic Health Records (EHRs) and other medical record systems to ensure accurate information.

+ Reach out to patients for communication regarding care and follow-up using the organization's preferred telephone system platform.

+ Schedule appointments with patients to facilitate timely access to healthcare services.

+ Conduct warm hand-offs to Registered Nurses (RNs) to ensure continuity of care.

+ Make follow-up calls to no-show patients to assess barriers and encourage attendance.

+ Maintain organized data systems to support efficient workflow and documentation.

Skills and Competencies

+ Demonstrates strong critical thinking and organizational skills in alignment with Transition of Care (TOC) processes and organizational standards.

Clinical Audits

+ Performs clinical audits to assess:

+ Compliance with applicable regulatory requirements and AHC policies and procedures.

+ Conducts chart audits in the following areas:

+ Transition of Care

+ Additional areas as identified by leadership

Compliance

+ Actively participates in initiatives to ensure compliance with:

+ Regulatory standards

+ Quality of patient care measures

+ Established industry best practices

Education and Training

+ Maintains up-to-date knowledge of current regulatory requirements and standards relevant to TOC.

Data Collection and Analysis

+ Gathers and analyzes data related to:

+ Transition of Care documentation and performance metrics

Additional Responsibilities

+ Other duties as requested or assigned

Operates under the supervision of the Transition of Care Program Manager

NON-ESSENTIAL SKILLS AND EXPERIENCE

+ Two (2) or more years’ experience in a Community Health Center

PATIENT-CENTERED MEDICAL HOME (PCMH)

All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team-based model to promote wellness and improve health outcomes.

ADHERENCE TO COMPLIANCE AND CODE OF CONDUCT

All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

PHYSICAL DEMANDS

While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT

While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, bloodborne pathogens, etc.) when working in the clinic area.

In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630 , if the essential functions of this position cannot be performed in a satisfactory manner by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization.