Essential Duties:

• Works with Care Coordination RN/LVN to promote and reinforce patient centered medical home concepts with patients and staff.

• Coordinates care of designated patients within the MHM primary care clinic providers, integrated healthcare team, specialists, Care Coordinator team members, Wesley Nurses, patients, and families to facilitate patient through the care system.

• Work with outside agencies for welfare checks and occasionally make home visits.

• Provides education to patient and family regarding patient's condition and ongoing care.

• Responds to calls and questions from patients, providers, and integrated healthcare team.


• Documents tracked outcomes for Care Coordination patients using appropriate terminology and abbreviations.

• Takes and documents patient vital signs (blood pressure, pulse, weight, height, other measures as assigned) both in the clinic and patient's home setting.


• Assists in the resolution of complaints, requests, and inquiries from patients.

• Monitor patients for changes in clinical symptoms in person at clinic, at home or by phone


• Follows processes implemented to improve patient's health outcomes.


• Performs other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:

High school diploma or general education degree (GED) required. Graduate of an accredited Medical Assistant program required; one year experience in a clinical setting; or equivalent combination of education and experience.

Language Ability:

Ability to read and interpret documents. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other team members. Translate between provider and patient/client. Fluent in English. Bilingual in Spanish required.

Reasoning Ability:

Ability to apply understanding to carry out instructions. Ability to deal with standardized situations with occasional or no variables.

Certificates and Licenses:

Currently registered by either of the following: The Texas Department of Aging and Disability Services, National Association for Health Care Professionals, National Healthcare Association required. BCLS certification required.

Computer Skills:

To perform this job successfully, an individual should have working knowledge of the Internet, Outlook, PowerPoint, Word and Excel applications. Experience with electronic health record software preferred.

Other:Must be able to drive and have access to a car; maintain valid driver's license and auto liability insurance.

Work Environment and Physical Demands:

The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the team member is exposed to a medical office environment having direct contact with patients and clients. Position may necessitate bending, stooping, twisting, turning, walking, climbing step stools, reaching, kneeling, crouching, sitting and standing for periods of time. Must be able to lift and maneuver 25 pounds. May require some evening and weekend hours.