Medical Assistant 1, General Surgery, Burligton

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Medical Assistant supports the delivery of safe, high-quality, and empathetic care across ambulatory settings. Under the supervision of licensed providers or clinical overseers, the MA performs direct patient care, assists with clinical operations, and supports care coordination all while helping ensure a smooth and efficient daily workflow.

Job Description:

Essential Duties & Responsibilities 

I.    Clinical Considerations and Decision Making: Ways in which the MA comes to understand the problems, issues or concerns of patients/families, to attend to relevant/critical information and to respond in concerned and involved ways.
    A.    Accountable for providing safe patient care by demonstrating organizational skills that maintain and coordinate safe delivery of quality care for assigned patients/families. 
    B.    Participates in a culturally competent plan of care that identifies patient problems, expected outcomes, and addresses preventative measures.
    C.    Delivers care that is specific to the age of the patient
    D.    Cares for patients as delegated by the provider, RN or LPN within scope of practice and competence.
    E.    Contributes information provided by the patient or family for the assessment of health status 
    F.    Evaluates outcomes of interventions within their scope and  follows directions on a modified plan of care

II. Collaborative Relationship: Collaborates, cooperates, and communicates with other health care personnel to ensure quality and continuity of care.
    A. Establishes collaborative relationships with nurses, physicians, other colleagues, patients and families.
    B. Participates in and supports the educational plan for patient and family.

III. Clinical Guidance: The MA, within the scope of his/her practice and department specific skills, is responsible for the nature and quality of care they provide for patients.  
    A.    Demonstrates appropriate behavior by adhering to unit policies and procedures and practice guidelines specific to the setting.
    B.    Demonstrates the ability to provide and maintain patient safety in the environment of care
    C.    Demonstrates skills as a responsive and supportive team member.
    D.    Demonstrates ability to fulfill role in regulatory compliance and readiness.

Clinical/Direct patient care (The procedures performed may vary from practice to practice based on specialties, department's staffing model and/or patient population.)
•    Greets, identifies, transports and/or escorts patients to exam room.
•    Accurately obtains all elements of the MA rooming standards.  Documents data in Electronic Health Record (EHR.)   Reports findings as needed to provider.  Using the Pended Order workflow, pends orders as needed for provider signature.
•    Prepares patient for examination:    
    o    Asks patient for and documents chief complaint, symptoms, and duration of symptoms in EHR
    o    Obtains history and reviews medication list. Asks patient if they need any medication refills and queues refills in EHR.
    o    Documents all drug and other allergies
    o    Documents smoking history
    o    Takes vital signs (Height, Weight, Blood Pressure, Pulse, Respiration, Temperature)
    o    Observes patient, documents and reports findings to provider.
    o    Alerts the provider when patient is ready and communicates pertinent clinical information
    o    Notifies provider of an abnormal vital signs, elevated pain scores or safety concerns.  
•    Assists the provider with the patient visit and care as required:
    o    Prepares special equipment, instruments and supplies as needed.
    o    Provides instructions to patient regarding any diagnostic test and procedure after they have been educated by the provider.
    o    Prepares and labels specimens obtained by the MA or the provider for transport based on the Labeling Policy.  Tests specimens as necessary and according to proper procedure.  Specimens may include, but not limited to:
            Blood (phlebotomy)
            Clean-voided urine
            Finger stick blood sugar tests
            Stool for occult blood
            Rapid strep testing
            UCGs (pregnancy tests)
            Urine for microalbumin
            Glycohemoglobin A1C
            Protime
            Assists with throat cultures, PAP smears, wound cultures, biopsies, and joint injections
    o    Performs electrocardiograms, spirometries, monofilament testing, vision and hearing testing according to departmental standards
    o    Assists with wound care 
    o    Assists with other testing, in accordance with medical assistance training
    o    Assists provider with minor procedures
    o    Documents testing/results per practice protocol
    o     Administers immunizations based on written provider orders (as allowed by the practice license.)
    o    Administers injections based on written provider orders (as allowed by the practice license.)
    o    Follows department procedures related to access to non-controlled medications, such as IV solutions and vaccines, when granted access to these medications as part of the job functions.  
    o    Performs Phlebotomy procedures (back up to phlebotomist) (drawing of blood, spinning of bloods)
•    Clinical and Quality/Improvement Competency
    o    Meets expectations and maintains competencies of new hire orientation skills checklist, annual competency verification and participates in education programs provided.
    o    Is alert to Quality Improvement and CQI issues as well as to unsafe working conditions.  Notifies manager of concerns.  Participates in unit based QI activities and is familiar with unit measurement data.

Non-Clinical/Indirect patient care
•    Pre-visit planning
    o    Organizes and prioritizes daily work to ensure patient needs are met and provider schedules run efficiently.
    o    Participates in huddles to anticipate, understand and address the daily needs of our patients and providers to ensure proper workflow 
    o    Reviews patient records against quality measures and best practice indicators and advises providers of potential documentation and care gaps
    o    Prepares supportive documentation  for scheduled appointments/procedures
            Reviews record for completeness before appointment and update as appropriate
            Inserts the required forms per procedure and department protocol
            Follows up with patient or specialist to ensure patient care plans since last appointment were followed and results are available for physician review
            
    o    Confirms that lab and other ancillary tests are performed and results documented
•    Post visit work
    o    Enters charges and reviews patient record for billing accuracy performing quality checks on ICD-10 and CPT codes and other related information in order to streamline the billing process per practice protocols.
    o    Assists the providers with work outside the visit related to managing a panel of patients.
    o    Partners with patient and family in supporting patients’ short and long term goals.
    o    Supports care coordination for identified patients across the continuum in collaboration with provider and community agencies
    o    Performs designated tasks related to tracking test results and may communicate normal lab and imaging test results, either written or verbally as directed by provider.
    o    
    o    Provides and reviews instructions to patient regarding any diagnostic test and procedures.  Provides patient with written education materials and diagnostic prep as needed.  
    o    Serves as a liaison with patients, families to physicians, case managers, 3rd party payers, et al.
    o    Reviews, manages and enters registry health data for identified patient populations
    o    Monitors patient progress by utilization of disease specific registries to proactively reach out to patients to meet their health care goals.

•    Assists in the maintenance of the EMR
    o    Scans miscellaneous loose reports into the EMR
•    Ensures exam rooms, supplies and equipment are maintained/stocked
    o    Prepares equipment and packages to be sent  for sterilization following site protocol
    o    Maintains appropriate supplies and linen.
    o    Prepares orders for routine medical supplies.  Monitors expiration dates and rotates inventory.
    o    Prepares, cleans and maintains equipment, addressing issues in a timely manner to ensure availability of equipment.
    o    Cleans and prepares the exam room and other patient areas between patients.
•    Communication
    o    Manages provider InBasket folders per department standards, including lab/test tracking and referrals.  
    o    Reviews faxes, letters, forms, etc. and completes as much necessary information within scope before handing off to provider.
    o    Receives patient messages and reviews with provider.
•    Administrative Support
    o    Provides back up or periodic administrative assistance to the practice as needed, including but not limited to 
            Answe