Medical Assistant - P3@Home

Essential Functions

• Schedule all patient home visit appointments for the P3@Home Nurse Practitioner, coordinating around patient availability, acuity, and geographic routing.
• Create and maintain accurate, complete patient charts in the EMR (Athena) for all P3@Home 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 P3@Home 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.
• Cook up 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.
• Absorb 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 P3@Home program and coordinate restocking of clinical supplies used during home visits.

Transitions of Care & Hospital Follow-Up

• Monitor discharge reports and transitions of care notifications for P3@Home patients to ensure timely follow-up visits are scheduled post-hospitalization or post-ER visit.
• Cook up 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.

Communication & Collaboration

• 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.