FIRSTHEALTH OF THE CAROLINAS Position Description

Position Specific Competencies: Certified Medical Assistant (CMA)

In addition to the following essential position competencies, other competencies may be required to meet changing organization needs.

1.   Uses an appropriate problem-solving approach to plan services.

1. Obtains vital signs and general health information for patient chart and prepares patients for examination.
2. Maintains patient health record in an up-to-date status especially regarding pain assessment and current medication sheet.
3. Assures documentation is complete, concise, and correct.
4. Prepares and maintains exam rooms and medical equipment for patient visits
5. Contributes to plan of care for individuals and groups of patients utilizing all principles to reduce medication errors when handling or calling in medications or refills.
6. Demonstrates initiative in suggesting and implementing problem solving approaches and planning performance of service.
7. Prepares and maintains exam rooms and medical equipment for patient visits regarding all safety checks and HIPAA guidelines and adapt same HIPAA principles to chart documentation and exposure as well as discussing PHI in front of anyone other than patient.
8. Triages patients and enters accurate and concise data into the EMR while paying attention to spelling and clarity.
9. Navigates the EMR system in an efficient manner.
10. Facilitates quality care management through best practice utilization of the clinic EMR.
11. Promotes continuity of care seen by appropriate actions notes and prompt follow up.
12. Answers phones, routes calls and or takes accurate message. Demonstrates a sense of urgency relating to a patient’s level of distress.
13. Triages basic patient care needs, generating a telephone encounter depending upon the situation. Assure a duplicate message has not already been started.
14. Manages the scheduling of patient appointments. Registers new patients and maintains current accurate up to date demographic and insurance information for all patients. Performs according to policy regulations associated with Privacy Notification, Medicare secondary, signed demographic registrations, consent to treat minor, etc.
15. Identifies barriers related to Social Determents of Health (SDOH) and notifies provider.
16. Verifies insurance eligibility, scans insurance card
17. Checks patients in and or out for visits in an appropriate manner. Accurate and appropriate use of ICD-10 and CPT codes
18. Processes patient referrals for tests and referrals to specialists. Monitors referral work queue for follow-up.
19. Assists nursing and or other clinic personnel in follow-up to ensure patient compliance, receipt of test results and reports from specialists.
20. Be proactive in contacting patients with test results.
21. Forwards requests for Medical Records to Release of Information Department.
22. Recognizes how fraud and abuse interplay into daily role.
23. Ensures orders are entered correctly to capture appropriate charges.
24. Refills medications according to medication refill guidelines.
25. Identifies barriers germane to patient’s individual needs being financial, emotional, physical, cultural, or spiritual (SDOH).
26. Astute and sensitive to patient satisfaction as it pertains to customer service- people skills in all clinical situations.

2.   Provides services with consideration of the recipient’s needs.

1. Ensures that patients are placed in exam rooms and seen by the provider in a timely manner.
2. Assists the provider as needed with examinations and procedures
3. Ensures the smooth transition of patients.
4. Assists in the collection of laboratory specimens and performance of tests on patients as ordered by the provider. Track lab and all tests for outcomes and follow-up.
5. Identifies clinical significance of data and informs provider appropriately and provides follow up accurate documentation.
6. Ensures that all lab results, interpretations, etc. are received in the patient charts in a timely manner. Always assesses for provider signature, patient notification, date and any required follow up.
7. Actively participates in department functions by suggesting strategies to improve outcomes, control cost, and or increase patient satisfaction.
8. Maintains work area in neat, organized manner.
9. Secures patient information in desk drawers or folders
10. Secures all receipts, cash drawer, etc. under lock and key overnight and when away from work area.
11. Locks computer system as needed when away from work desk to protect PHI for patients.
12. Greets and direct patients and visitors in a courteous manner, informing them of delays or changes in patient flow.
13. Manages appointment schedule to ensure provider efficiency and patient satisfaction.
14. Monitors the reception area to ensure patient comfort and prompt response to patient distress or concerns.
15. Wears FH name badge and introduces self to patient as needed and required by the situation.

3. Uses equipment/supplies correctly.

1. Ensures that equipment and other instruments are properly set up for the providers’
2. Maintains the medical supplies necessary for providers to perform their

4.   Uses appropriate safety and infection control measures.

1. Ensures that all OSHA regulations and other appropriate policies are followed
2. Actively participates in the established QI/Risk Management Program.
3. Wear gloves and follow Body Substance Isolation Standards whenever examining the patient or with contact toblood or body fluids
4. Ensures all needles are placed in sharps containers and all material with blood or body fluids are disposed of properly
5. Ensures that all exam rooms and equipment are thoroughly cleaned between patients.

5.   Teaches/directs/advises/informs others in an appropriate manner timely manner.

1. Assists office personnel with scheduling and preparing follow-up appointments as relevantto clinical co-morbidities.
2. Arranges for patient testing, admissions, and referrals
3. Teaches patients according to provider’s instructions and in conjunction with age-appropriate guidelines
4. Utilizes EMR to support patient education and documents accordingly.

6.       Reports/records information appropriately.

1. Enters and records patient information in EMRin a concise and accurate
2. Ensures that all test results, interpretations, etc. are received in patient EHR in a timely manner.
3. Utilizes reports and data generated by the EMR to augment care by seeking out patients who need specific follow up such as but not limited to annual mammograms, colonoscopy, etc.
4. Uses approved format for recording and reporting messages. i.e., telephone encounter, etc.
5. Maintains written reports of all situations requiring manager’s attention.
6. Reconciles cash receipts and reports as instructed by policy twice daily, or when MOA must leave money drawer for an extended period. Prints end of day summary. 
7. Monitors habitual no shows or late patients, reporting and communicating as needed to clinic manager.
8. Enters and records patient information in EMR in a concise and accurate manner, paying attention to lot number and expiration date, patient tolerance of injections, proper consent forms, and authorizations on

7.     Quality Improvement

1. In preparation for patient appointments, contact facilities will as necessary to ensure the appropriate paperwork is index in the patient’s EMR medical record prior to being seen by the provider – Examples: surgical reports, pathology reports, home health summary of care, etc.
2. Responds to the follow-up action plans sent by providers goaled at achieving maximum level of care continuity in preparation for designated patient appointment – Examples: Remind patient to bring blood pressure log to appointment
3. CMA will monitor and utilize as needed the Quality Panel Metrics/Health Maintenance tab to facilitate proactive management of patient care and close care.
4. BLS required and SPICE (not required), but employee will be required to complete at some point.

8.       In addition to the job description stated above, the CMA will also be accountable for the following responsibilities:

1. Promote proactive communication with all patients while being sensitive to those that are high risk and whose care is complicated by:
   • Recent inpatient admission hospital
   • Noncompliance
   • Uncontrolled chronic co-morbidities
   • Problematic no-show rate

Compliance to competencies are evaluated by Outstanding, Successfully and Needs Improvement. It is the judgment of the clinic manager and supported by objective documentation under comments when either Outstanding or Needs Improvement are given to any of these competencies.

FIRSTHEALTH OF THE CAROLINAS Position Description

Position Specific Competencies: Licensed Practical Nurse (LPN)

In addition to the following essential position competencies, other competencies may be required to meet changing organization needs.

1.   Uses an appropriate problem-solving approach to plan services.

1. Obtains vital signs and general health information for patient chart and prepares patients for examination.
2. Maintains patient health record in an up-to-date status especially regarding pain assessment and current medication sheet.
3. Assures documentation is complete, concise, and correct.
4. Prepares and maintains exam rooms and medical equipment for patient visits
5. Contributes to plan of care for individuals and groups of patients utilizing all principles to reduce medication errors when handling or calling in medications or refills.
6. Demonstrates initiative in suggesting and implementing problem solving approaches and planning performance of service.
7. Prepares and maintains exam rooms and medical equipment for patient visits regarding all safety checks and HIPAA guidelines and adapts same HIPAA principles to chart documentation and exposure as well as discussing PHI in front of anyone other than patient.
8. Triages patients and enters accurate and concise data into the EMR while paying attention to spelling and clarity.
9. Navigates the EHR system in an efficient manner.
10. Facilitates quality care management through best practice utilization of the clinic  EMR
11. Promotes continuity of care seen by appropriate actions notes and prompt follow up.
12. Answers phones, routes calls and or takes accurate message. Demonstrates a sense of urgency relating to a patient’s level of distress.
13. Triages basic patient care needs, generating a telephone encounter depending upon the situation. Assure a duplicate message has not already been started.
14. Identifies barriers related to Social Determinants of Health (SDOH) and notifies provider.
15. Accurate and appropriate use of ICD-10 and CPT codes.
16. Forwards requests for Medical Records to Health Information Management Systems.
17. Recognizes how fraud and abuse interplay into daily role.
18. Ensures orders are entered correctly to capture appropriate charges.
19. Refills medications according to medication refill guidelines.
20. Identifies barriers related to patient’s individual needs being financial, emotional, physical, cultural, or spiritual (SDOH).
21. Astute and sensitive to patient satisfaction as it pertains to customer service- people skills in all clinical situations.

2.   Provides services with consideration of the recipient’s needs.

1. Ensures that patients are placed in exam rooms and seen by the provider in a timely manner.
2. Assists the provider as needed with examinations and procedures.
3. Ensures the smooth transition of patients.
4. Assists in the collection of laboratory specimens and performance of tests on patients as ordered by the provider. Track lab and all tests for outcomes and follow-up.
5. Identifies clinical significance of data and informs provider appropriately and provides follow up accurate documentation.

1. Ensures that all lab results, interpretations, etc. are received in the patient charts in a timely manner. Always assesses for provider signature, patient notification, date and any required follow up.
2. Actively participates in department functions by suggesting strategies to improve outcomes, control cost, and or increase patient satisfaction.
3. Maintains work area in neat, organized manner.
4. Secures patient information in desk drawers or folders.
5. Locks computer system as needed when away from work desk to protect PHI for patients.
6. Greets and direct patients and visitors in a courteous manner, informing them of delays or changes in patient flow.
7. Manages appointment schedule to ensure provider efficiency and patient satisfaction.
8. Monitors the reception area to ensure patient comfort and prompt response to patient distress or concerns.
9. Wears FH name badge and introduces self to patient as needed and required by the situation.

3. Uses equipment/supplies correctly.

1. Ensures that equipment and other instruments are properly set up for the providers’
2. Maintains the medical supplies necessary for providers to perform their

4.   Uses appropriate safety and infection control measures.

1. Ensures that all OSHA regulations and other appropriate policies are followed
2. Actively participates in the established QI/Risk Management Program.
3. Wear gloves and follow Body Substance Isolation Standards whenever examining the patient or coming in contact with blood or body fluids.
4. Ensures all needles are placed in sharps containers and all material with blood or body fluids are disposed of properly.
5. Ensures that all exam rooms and equipment are thoroughly cleaned between patients.

5.   Teaches/directs/advises/informs others in an appropriate manner.

1. Serves as communication link between the patient and the provider.
2. Administers prescribed medications as directed and instructs patients on the proper use of each medication.
3. Accurately and clearly communicates data to the appropriate healthcare provider in a timely manner.
4. Assists office personnel with scheduling and preparing follow-up appointments as germane to clinical co-morbidities.
5. Arranges for patient testing, admissions, and referrals.
6. Teaches patients according to provider’s instructions and in conjunction with age-appropriate guidelines.
7. Utilizes EMR to support patient education and documents accordingly.

6.       Reports/records information appropriately.

1. Enters and records patient information in EMR in a concise and accurate manner.
2. Ensures that all test results, interpretations, etc. are received in patient  EMR in a timely manner.
3. Utilizes reports and data generated by the EMR to augment care by seeking out patients who need specific follow up such as but not limited to annual mammograms, colonoscopy, etc.
4. Uses approved format for recording and reporting messages. i.e., telephone encounter, etc.
5. Maintains written reports of all situations requiring the manager’s attention.

1. Monitors habitual no shows or late patients, reporting and communicating as needed to clinic manageEnters and records patient information in EMR in a concise and accurate manner, paying attention to lot number and expiration date, patient tolerance of injections, proper consent forms, and authorizations on file.

7.     Quality Improvement

1. In preparation for patient appointments, will contact facilities as necessary to ensure the

appropriate paperwork is index in the patient’smedical record prior to being seen by the provider – Examples: surgical reports, pathology reports, home health summary of care, etc.

1. Responds to the follow-up action plans sent by providers goaled at achieving maximum level of care continuity in preparation for designated patient appointment – Examples: Remind patient to bring blood pressure log to
2. LPN will monitor and utilize as needed the Quality Panel Metrics/Health Maintenance tab to facilitate proactive management of patient care and close care

1. Promote proactive communication with all patients while being sensitive to those that are high risk and whose care is complicated by:
   • Recent inpatient admission hospital
   • Noncompliance
   • Uncontrolled chronic co-morbidities
   • Problematic no-show rate

1. Proactive communication is defined as, but not limited to:
   • Placing follow up calls to patient care giver post clinic encounter; hospital discharge; recent non-compliant event (failure to pick up medication, etc.).
   • All no-show appointments are followed according to Policy AR-0009 75-1003PL.

Compliance to competencies are evaluated by Outstanding, Successfully and Needs Improvement. It is the judgment of the clinic manager and supported by objective documentation under comments when either Outstanding or Needs Improvement are given to any of these competencies.

Written: 10/24/14

Revised: 01/2017, 02/2019, 09/2021

Reviewed: 11/2022, 12/2024