Under the direct supervision of the Site Manager and under a matrix system of supervision and guidance of the

PCMH Care Coordinator (PCMH) and Director of Nursing, the Certified Medical Assistant (CMA) assists

patients and their families in all aspects of their clinical interaction with their provider. The CMA is an integral

part of the Care Team and ensures that all patients have optimal health outcomes.

Duties and Responsibilities

• Greet patient and family cordially at every visit, using cultural sensitivity and customer service skills. At end of visit, escort patient to check out and ensure that concerns and questions were addressed.
• Assist providers within the patient care team with the care of patients including obtaining information on reason for visit, medical history, social history, family history, medications, allergies, vital signs, and others. Responsible for entering information into the electronic medical records, verifying accuracy and reviewing answers at subsequent visits.
• Ask patients if they have recently seen another provider, received new medications or were recently in the hospital. Obtain and update record with this information and obtain discharge summaries and other information from the hospital interface.
• Participate in Care Team meetings (i.e., huddles) to prepare for patient visits and anticipate needs.
• Assist in providing translation if needed or obtaining access to language line if the provider indicates.
• Maintain privacy and confidentiality of all patients by following HIPPA regulations and policies and procedures set for by the Zufall Health Center.
• Remain present in the exam room during pelvic, breast, genital and rectal examinations. May remain in the exam room for other evaluations unless the provider indicates that there is no need. If that is the case, the MA will remain close to the examination area so as to be available should the provider need them.
• Inform provider that patient is ready and review clinical information to expedite visit. Maintain doors to exam room closed while patient is waiting for provider.
• Assist in the educational process during and after the visit, including translation of instructions, reviewing of materials, answering questions, and ensuring that all questions are addressed by provider.
• Ensure that patient understands instructions and obtains a follow up appointment if indicated by the provider.
• Participate in collaborative initiatives and PDSA’s as directed by PCMH, Director of Nursing, and Chief Medical Officer

Specific Duties

• Obtain vital signs including height, weight, blood pressure, temperature, pulse, respiration rate and pain scale at every visit unless not required by type of visit (e.g. PPD) or if provider does not require (e.g. infant checkups). Ensure that data is entered correctly and calculations for BMI (in adults) and BMI% and Head Circumference according to the growth chart (in children) are correct.
• Have a watch with a second hand and a stethoscope when on duty to perform above tasks.
• Verify data as above and repeat a blood pressure reading at the end of the interview using a manual cuff if the patient initially had an elevated blood pressure reading.
• Follow standing orders for patients with diabetes, patients with hypertension, patients who present with burning on urination, patients who have a delayed menstrual period and others as developed by providers and approved by the Chief Medical Officer and Director of Nursing.
• Obtain finger stick samples for glucose, hemoglobin, and hemoglobin A1C as per provider order or following standing orders. Obtain urine specimen for dip or pregnancy test per provider order or standing orders, and urine culture with clean catch technique per provider order. Obtain finger stick sample for rapid HIV test if trained to perform and as ordered by provider.
• Inform the provider of results of all tests done in the examination room, chart controls and enter results in the EHR.
• Successfully complete competencies for all in house tests done as per CLIS and NJ State Regulations.
• Work with providers to determine whether visit is billable to state and if patient is eligible for referral to our contracted subspecialists.
• Ensure that every room is clean and specimens are properly disposed of after every patient.
• Ensure that, at the end of the day, examination rooms and other clinical areas are clean. Ensure that tables and chairs are wiped down and any equipment, such as the SPOT machines and any wall units are cleaned with antibacterial wipes.
• Ensure that counters and exam tables are wiped down and free of dirt and other substances.
• Ensure that in every exam room, drawers are stocked and locked when appropriate.
• Enter medications into the EHR, listing prescription medications first, followed by over-the-counter medications and supplements.
• Assist the provider in recording medications given from the center’s stock by entering date of dispensing, patient’s name, medication name, lot number and expiration date, followed by the provider’s initials. Ensure that medications that have a cost are paid for by the patient before these are given out.
• Assist provider in administering ordered vaccines by preparing vaccine in appropriate syringe and in the appropriate amount and made ready for verification by provider prior to administration. Administer as per Certification, as per training and as per provider.
• Assist in obtaining labs from fax administrator and attach hard copies to patient documents if needed.
• Assist with completion of forms, insurance referrals (to be sent to Referral Specialist if patent has insurance and requires pre-authorization), notes for work or school and other paperwork.
• Provide PCMH with a list of supplies as soon as it is noted that the last box of the item has been opened and in use.
• Check supplies in all exam rooms daily, check stock in storage areas weekly, and complete list of needed supplies on a daily basis as needed.
• Perform other related duties as assigned by the PCMH or Site Administrator and the Director of Nursing.
• Participate in annual competencies for the following, but not limited to: translation, vital signs and measurements, doing TB skin tests, all waived POC lab tests, infection prevention and control, sterilization process and instrument preparation, OSHA, immunization administration and reconciliation, standing orders, medical waste management, patient preparation for the visit, cultural competency and customer service.

Additional Duties as CMA I with EKG Certification

• All duties listed above under Duties and Responsibilities.
• Perform EKG when ordered by provider following proper technique, making sure privacy is maintained, documenting client name, date of birth and date done on the EKG. A person complaining of chest pain is to be evaluated by the provider first before obtaining the EKG. The CMA is to have the EKG available in case the provider requests one.

Additional Duties as CMA I with Phlebotomy Certification

• All duties listed above under Duties and Responsibilities.
• Perform phlebotomies as per provider orders and according to standard procedure and using aseptic technique. Before blood draw, verify two sources of identification by asking the patient his or her name and his or her date of birth and verifying the order.

Additional Duties as CMA II

• All duties listed above, including Additional Duties as CMA I with EKG Certification and Additional Duties as CMA I with Phlebotomy Certification.

• Minimum High School Diploma or GED
• Have current certification as a Medical Assistant
• Have current certification for EKG, Phlebotomy and BLS
• Minimum 6 months experience in clinical/medical setting, or at least 120 hours of externship experience