Theoria Medical is a physician-led post-acute care organization delivering value-based care in the skilled nursing facility (SNF) setting. Instead of asking patients to come to us, we bring high-quality, patient-centered care directly to them. We are leading the charge in healthcare innovation, bringing multispecialty provider services and forward-thinking technology to skilled nursing facilities across the country.
We're looking for a Medical Assistant to join our post-acute care team on a temporary basis to serve as the vital connection between residents, providers, nursing staff, and families, coordinating care, facilitating telemedicine visits, and reinforcing patient education to drive better outcomes in a value-based care model.
- Facilitate in-room telemedicine visits and schedule acute, follow-up, and routine provider appointments
- Prepare and support residents during provider visits, including positioning and documentation
- Update EHRs with medical histories to support care plans and visit encounters
- Support smooth transitions of care across the post-acute continuum, including referrals and follow-up appointments
- Facilitate prior authorizations and assist residents with ACO Voluntary Alignment forms
- Reinforce provider instructions and educate residents on nutrition, fall prevention, medication reminders, and general wellness
- Distribute provider-approved materials and route clinical concerns to licensed staff or providers
- Maintain accurate documentation in the EMR and support regulatory compliance and quality initiatives
- Fosters a culture of best-demonstrated practices, customer and peer service orientation, measurement, performance, accountability, and continuous improvement
- Manages the Transition of Care process from admission to transition home (i.e., admission, discharge planning, and follow-up)
- Monitors active patients across care settings (hospitals and SNFs)
- Serves as a resource for the patient and their family to help solidify the discharge and treatment plan
- Facilitates and clarifies the patient’s goals of care with the facilities and attending physicians
- Assists with discharge planning from inpatient or skilled nursing settings
- Works collaboratively with the clinical coordinator to ensure discharge data is appropriately documented and transition-of-care visits are scheduled and verified with the patient/family
- Will collaborate with the Community Medical Director daily to review the appropriateness of discharge plans
- Reviews with the CMD the medical necessity of Home Health orders and DME orders, and follows up with those HH and DME agencies on their treatment plan
- Facilitates access for patients to verify their ancillary services (e.g., DME, Home Health, outpatient rehab) are in place and meeting their needs
- Attends Interdisciplinary Team (IDT) meetings and provides additional information on patients
- Serves as the face of [Company Name] in the hospital/SNF when physicians cannot be onsite (e.g., bringing in notes, POLST, etc.); patients recognize them as part of the [Company Name] program
- Assists physicians with communicating with the attending of record
- Develops relationships in the admitting, ED, and Case Management departments in the facility setting
- Coordinates with the facility’s Case Management and Social Work teams on the discharge
- Obtains access to clinical records in the facility setting, and reviews and facilitates medical-records transfer to [Company Name]
- Ability to explain the [Company Name] care model and engage new members into the program
- Other tasks needed to accomplish the team’s objectives and goals
- Prior experience as a Medical Assistant in a clinical or care-coordination setting; Health Plan / Hospice Liaison experience preferred
- Problem solving, thinking autonomously, and owning the solution
- History of successful outcomes or quality-driven practices
- Advanced computer skills (e.g., Excel filtering and advanced features, Google/Gmail, etc.)
Travel: Local travel may be required, up to 30 miles one way
Physical Demands: Ability to lift up to 20 lbs. independently and assist with resident transfers involving greater weights as part of a team; ability to stand for extended periods; ability to travel to patient locations (e.g., home, hospital, SNF); fine motor skills and visual acuity required.
- Ex: 6-hour facility shifts for full-time positions (rounds generally start between 7-10 a.m.)
Employees must be able to perform the essential functions of this position satisfactorily, with or without reasonable accommodation. Theoria Medical conducts criminal background checks and pre-employment drug testing on all candidates upon acceptance of a contingent offer.