Medical Assistant

General Summary:

The Community Health Worker / MAT Care Coordinator / Clinical Support Nurse is a hybrid role responsible for supporting patients through outreach, care coordination, MAT program follow-up, and clinical nurse visits, including phlebotomy and other delegated clinical services within scope of licensure and training. This position helps improve patient access, engagement, and continuity of care by addressing both clinical and non-clinical barriers, supporting provider plans of care, and promoting positive health outcomes.

This role serves as a bridge between patients, providers, care teams, and community resources, with a strong focus on patients with chronic conditions, behavioral health needs, substance use disorders, and other complex health or social needs.

Team members in this role may be cross trained in other functions to support clinic operations, improve teamwork, and help meet patient and organizational needs.

Responsibilities:

• Coordinate patient care and provide support for patients with medical, behavioral health, substance use, and social service needs.

• Conduct outreach to patients by phone and in person to support engagement, appointment compliance, follow-up care, and continuity of services.

• Assist patients with navigating the healthcare system, accessing internal services, and connecting with community resources that address barriers such as transportation, housing, food insecurity, insurance, and medication access.

• Support patients participating in Medication-Assisted Treatment services through intake coordination, appointment scheduling, follow-up, education, and ongoing communication regarding treatment needs and program expectations.

• Collaborate with providers, nursing, behavioral health, care management, and other team members to support whole-person care and ensure appropriate coordination of services.

• Perform nurse visits in accordance with provider orders, standing orders, protocols, and organizational policy.

• Obtain and document vital signs, screenings, medication reconciliation, health histories, and other clinical information as appropriate during patient visits.

• Provide patient education and reinforce care plans, treatment recommendations, medication instructions, and preventive health guidance.

• Perform phlebotomy, specimen collection, labeling, processing, and preparation for transport in accordance with clinic protocol and competency requirements.

• Administer injections, immunizations, point-of-care testing, and other delegated clinical duties within scope of licensure, training, and organizational policy.

• Monitor for abnormal findings, patient concerns, or barriers to treatment and communicate these to the appropriate provider or team member promptly.

• Track and document patient contacts, care coordination activities, missed appointments, follow-up needs, and outcomes in the electronic health record.

• Participate in team huddles, case reviews, quality initiatives, and population health efforts aimed at improving patient outcomes and closing care gaps.

• Maintain confidentiality and comply with HIPAA, 42 CFR Part 2, infection control standards, and all applicable organizational policies and regulatory requirements.

• Travel between clinic locations or community sites as needed and perform other duties assigned in support of patient care and operations.

• Other duties as assigned.

Education: High school diploma or GED certification

Experience:

Other Requirements: None