Medical Assistant P3Home

The Medical Assistant is a specialized field-capable clinical support role that works exclusively within the Program. This program delivers in-home primary care visits to patients who are homebound bedbound or chronically ill and unable to attend scheduled office visits. The primary goal of the program is to keep high-risk patients out of the emergency room and hospital by providing consistent proactive medical care in the home setting.

The MA serves as the operational backbone of the program working closely with the Nurse Practitioner to coordinate all aspects of patient care. This role requires a high degree of clinical knowledge care coordination expertise and compassionate communication as patients and their families often depend on this individual as their primary point of contact for all medical and social needs.

• Schedule all patient home visit appointments for the Nurse Practitioner coordinating around patient availability acuity and geographic routing.
• Create and maintain accurate complete patient charts in the EMR (Athena) for all patients including demographic entry insurance verification and care history documentation.
• Perform thorough chart preparation prior to each visit reviewing recent labs imaging specialist notes medication lists and outstanding care gaps to ensure the NP has complete information at the time of the visit.
• Document visit outcomes care coordination activities and follow-up actions in the EMR accurately and in a timely manner.

• Serve as the primary point of contact for patients and their families responding to calls and inquiries related to medical needs appointments referrals and community resources.
• Coordinate at-home laboratory services including scheduling mobile phlebotomy and ensuring results are routed to the NP for timely review and follow-up.
• Arrange home-based diagnostic imaging services as ordered by the NP.
• Coordinate referrals to and communication with home health agencies to ensure ordered services are initiated authorized and followed through.
• Facilitate durable medical equipment (DME) orders and delivery coordination ensuring patients receive necessary equipment in the home.
• Connect patients and families with community resources social services transportation assistance and other support programs as needed.
• Monitor and follow up on outstanding orders referrals and care coordination tasks to ensure nothing falls through the cracks between visits.

• Accompany the Nurse Practitioner on home visits as needed to provide clinical support assist with procedures obtain vital signs and document care in real time.
• Assist with clinical tasks during home visits per scope and NP direction which may include wound care support specimen collection or equipment operation.
• Maintain accurate supply inventory for the program and coordinate restocking of clinical supplies used during home visits.

• Monitor discharge reports and transitions of care notifications for patients to ensure timely follow-up visits are scheduled post-hospitalization or post-ER visit.
• Coordinate with Nurse Case Managers discharge planners and home health agencies to facilitate smooth transitions back to home-based care.
• Proactively identify patients at elevated risk for readmission and escalate to the NP for expedited visits.

• Maintain professional compassionate communication with patients families and caregivers recognizing that this population is often medically complex emotionally vulnerable and highly dependent on support.
• Collaborate with clinic-based Practice Managers Nurse Case Managers Care Navigators Referral Coordinators and other P3 team members to ensure continuity of care for shared patients.
• Communicate with specialists pharmacies and external providers as needed to support patient care plans.
• Participate in team huddles care management meetings and program-level performance reviews.

• Strong clinical knowledge base and understanding of chronic disease management homebound patient populations and preventive care.
• Proficiency in EMR systems (Athena preferred) including chart creation documentation scheduling and referral management.
• Excellent care coordination skills with demonstrated ability to manage multiple patients open tasks and competing priorities simultaneously.
• Strong interpersonal and communication skills with patients families providers and external agencies.
• Ability to function independently in the field with minimal supervision while maintaining high standards of documentation and follow-through.
• Knowledge of DME home health mobile lab and imaging coordination processes.
• Familiarity with Medicare Advantage managed care and value-based care principles.
• Comfort with travel and the physical demands of field-based work including transporting supplies and working in varied home environments.

Required: High school diploma or GED; current Medical Assistant certification (CMA or RMA); 2 years of clinical MA experience in a healthcare setting; strong experience with EMR documentation and patient scheduling.

Preferred: Experience working with homebound geriatric or medically complex patient populations; familiarity with home health DME or care coordination workflows; bilingual fluency in English and Spanish.

Pay Range: $20-25/hr depending on experience

People. Passion. Purpose. At P3 Health Partners our mission is to guide communities to better health unburden clinicians align incentives and engage patients. We are a physician-led organization committed to transforming healthcare from sickness care to wellness guidance. If you are passionate about making a difference eager to grow and thrive in a collaborative environment we invite you to join our team.

Required Experience:

Junior IC