Primary Function - CMA

Under supervision the incumbent is responsible for a variety of administrative and clinical skills established by the Primary Care Nurse Manager/MD/RN Lead. Under supervision he/she is responsible for following the plan of care established by the physician.  The Certified Medical Assistant assists in performing and providing clinical care, duties, and tasks for patients of all ages.

Job Description

Recognizes and reports to the registered nurse or medical provider abnormal findings related to vital signs, clinical signs and symptoms, and laboratory findings.

Implements administrative duties, but not limited to:

• Answering phones and scheduling appointments.
• Greet patients and updates patient registration information.
• Preparing and typing correspondence.
• Processing, coding, and completing insurance claim forms.
• Processing mail.
• Maintaining supplies and equipment.
• Arranging for hospital admissions and outside referrals for the physician with direction from a physician or physician’s assistant.
• Calling prescriptions to the pharmacy for the physician.

Implements clinical care including, but not limited to:

• Takes and records vital signs and reports deviations to the registered nurse or physician.
• Recording patient interview, history and chief complaint.
• Providing patient education with regards to CIH policies such as explanation of the pain contract, medications, home treatments, and special diets.
• Preparing patients for examinations and performing routine screening tests.
• Phlebotomy and collection of other lab specimens (urine, stool, throat cultures and sputum).
• Performing basic lab tests.
• Performing EKGs.
• Preparing and administering medications with physician’s authorizations. Not to include IV preparation or administration.
• Change dressing, applying bandages, removing sutures and other first aid procedures.
• Maintaining supplies, equipment, stocking, and sterilizing instruments.
• Completes finger stick glucose monitoring.
• Assists primary care providers with diagnostic test, examining patients, etc.
• Monitors intake and output, including monitoring IVs.
• Performs vision acuity (Snellen).
• Documents vital signs and other medical data to the appropriate record.
• Initiates appropriate resuscitative measures in an emergency situation. 
• Operates a variety of specialized medical equipment, such as suction pumps, oxygen equipment, automatic BP cuffs, and oxygen saturation units, etc.  Recognizes malfunctioning and unsafe equipment and initiates corrective action.
• Initiates appropriate action when safety measures are required to protect patients.
• Maintains a safe environment through the practice of Universal Precautions and Body Substance Isolation, medical waste/chemical management and containment.  Isolates infected patients.  Cleans patient contact areas and equipment according to policies and OSHA regulations.
• Promotes patient advocacy and confidentiality.
• Directly observes and evaluates patient care.

• Participates in ongoing nursing quality assurance program.
• Utilizes the Electronic Health Record (EHR) for documentation of clinical visits, interventions and screenings and assessments.
• Utilizes the care management platform for documentation of contacts, screenings and assessments and notifications.
• The Certified Medical Assistant will function in the Outpatient and/or Satellite Clinics under the supervision of the Director, Division of Clinical Services/Director, Division of Nursing or his/her designee to insure patient care is provided in a safe and efficient quality manner.
• May be subject to on-call and callback.

• Demonstrates the ability to establish good interpersonal working relationships with patients and staff.
• Assists with and makes recommendations about supplies and equipment needs.
• Maintains clean, neat, and safe work environment.
• Demonstrates ability and willingness to adapt to special circumstances, such as, staffing shortages, patient emergencies, fluctuations in census, and disasters.

   

• The Certified Medical Assistant provides nursing care according to established procedures; under the supervision of the charge nurse or supervisor.This is done under the supervision of the Director, Division of Clinical Services/Director, Division of Nursing or his/her designee.The work is evaluated for technical soundness and adherence to professional standards.

• May be necessary to work when Administrative leave is granted if patient care would be compromised.

Job Knowledge

• Knowledge and skill to perform basic clinical care to acutely ill patients and assist patients in their daily living activities.

• Knowledge of principles, practices, techniques, and theories of professional nursing in order to plan and provide nursing care to meet the physical, emotional, spiritual, and socio-cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2 years), Latency (6-9 years), Preadolescence (10-12 years), Early
• Adolescence (13-15 years), Adolescence (16-20 years), Adult (21-64 years), and Elderly
• (65-+ years).
• Knowledge and skill to assist the primary care provider in treatment and examinations performed in the Outpatient setting.

 

• A practical knowledge of performing prescribed treatment plans such as dressing changes or soaks.
• Knowledge of proper handling and collection of specimens, performing vital signs and recognizing abnormal values.

• Basic knowledge of diseases and illnesses and the ability to recognize and report changes in the patient's condition to the physician.

 

• A practical knowledge of the medical facility's organization and services, the basic rules and regulations governing visitors and patient treatment, COBRA, and practical knowledge of standard procedures, medical records, and medical terminology.
• A basic knowledge of diseases, medical and surgical procedures, as well as standard abbreviations used by the medical staff.

• A thorough knowledge of recording and documenting medical information.
• Knowledge and skills in operating specialized medical equipment, such as suction pumps, oxygen equipment, etc.
• Applicant must have a valid North Carolina driver’s license.

Education, Licensure, Certification, and Experience

• An Associate of Applied Science degree from a CAAHEP-accredited college program. Preferred.
• A nationally recognized certification as a Certified Medical Assistant (CMA).
• Current Basic Life Support (BLS), or Advanced Cardiac Life Support (ACLS) may be substituted, is required of the position. Can be acquired through the facility following appointment to position.
• 2 years of experience is preferred. Proficiency rated at 6 weeks.

Complexity of Duties

The incumbent will be responsible for actively participating with a team of healthcare providers to provide and coordinate care. The incumbent will be expected to be positive and productive in the CMA role. The CMA role requires flexibility and the ability to work with team members who possess a variety of personalities. The CMA role necessitates the incumbent to always maintain a high level of integrity, poise, and control.

Supervision Received

The LPN plans, schedules, and provides care in coordination with the medical care plan and attempts to solve problems with MD/RN guidance. This is done under the supervision of the RN Lead and the Director of Nursing for Primary Care.  The work is evaluated for technical soundness and adherence to professional standards.

Contact with Others

Contacts are with patients, families, hospital personnel, and community agencies.

Contacts with patients and families are to provide and assist with care.  With hospital personnel and community agencies, contacts are to exchange information for the purpose of coordinating patient care activities. The Nursing Assistant is assigned duties based upon the diagnosis of the patient, his/her condition, and special circumstances related to his/her needs.

Confidential Data

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical and personnel records and all other pertinent information that comes to the individual’s attention or knowledge.  The Privacy Act carries both civil and criminal penalties for unlawful disclosure of records.  Violation of such confidentiality shall be cause for adverse actions.

Responsibility for Accuracy

The incumbent is responsible for accuracy of work performed.  The charge nurse, supervising registered nurse, or immediate supervisor reviews work for accuracy and determines steps to prevent errors from reoccurring.  The Nursing Assistant will follow the plan of care established by the registered nurse according to individual patient needs and established hospital policies and procedures.  The purpose of the work is to provide patient care that contributes to completion of the prescribed plan of care and discharge of the patient.  The work affects the physical and psychosocial well being of the patients and their families.  Completion of duties affects the attitude of patients and efficiency with which the hospital provides service and therefore could have a negative effect on patient outcomes.

Guidelines consist of nursing and medical policy and procedures, standing orders, standards of care, and hospital and agency policies.  Must, also, comply with FPM, DHHS, PHS, IHS, and State regulations. The employee follows the medical or nursing care plan developed through the physician or registered nurse either in the clinical or inpatient setting.  The employee determines the order and sequence of care provided to the patient based on the patient's condition and priorities of need. 

Mental/ Visual/ Physical Effort

Work in the various services within the nursing department requires considerable walking, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers.  These same activities are required in moving equipment and medical supplies.

Resourcefulness and Initiative

The Certified Medical Assistant works under the direction and supervision of a physician, however nursing may be asked to verify various competencies. 

Environment

Must be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases.   

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to tall patients/customers by seeking out opportunities to be of service.

Primary Function - LPN

Under supervision the incumbent is responsible for a variety of administrative and clinical skills established by the RN Case Manager/RN Lead/Primary Care Nurse Manager. Under supervision he/she is responsible for following the plan of care established by the physician.  The Licensed Practical Nurse assists in performing and providing clinical care, duties, and tasks for patients of all ages. Primarily works 1:1 with the Primary Care Provider (PCP). Participates in pre-visit planning to anticipate patient and PCP needs.

Job Description

Recognizes and reports to the registered nurse or medical provider abnormal findings related to vital signs, clinical signs and symptoms, and laboratory findings.

Implements administrative duties, but not limited to:

• Managing daily schedule.
• Answering phones and scheduling appointments.
• Greet patients and updates patient registration information.
• Preparing and typing correspondence.
• Processing, coding, and completing insurance claim forms.
• Processing mail.
• Maintaining supplies and equipment.
• Arranging for hospital admissions and outside referrals for the physician with direction from a physician or physician’s assistant.
• Calling prescriptions to the pharmacy for the physician
• Completing forms.

Implements clinical care including, but not limited to:

• Takes and records vital signs and reports deviations to the registered nurse or physician.
• Recording and documenting chief complaint.
• Administers immunizations, depo, B12
• Providing patient education with regards to CIH policies such as explanation of the pain contract, medications, home treatments, and special diets.
• Preparing patients for examinations and performing routine screening tests.
• Phlebotomy and collection of other lab specimens (urine, stool, throat cultures and sputum).
• Performing basic lab tests.
• Performing EKGs.
• Preparing and administering medications with physician’s authorizations.
• Change dressing, applying bandages, removing sutures and other first aid procedures.
• Maintaining supplies, equipment, stocking, and sterilizing instruments.
• Completes finger stick glucose monitoring.
• Assists primary care providers with diagnostic test, examining patients, etc.
• Performs vision acuity (Snellen).
• Documents vital signs and other medical data to the appropriate record.
• Operates a variety of specialized medical equipment, such as suction pumps, oxygen equipment, automatic BP cuffs, and oxygen saturation units, etc.  Recognizes malfunctioning and unsafe equipment and initiates corrective action.
• Initiates appropriate action when safety measures are required to protect patients.
• Maintains a safe environment through the practice of Universal Precautions and Body Substance Isolation, medical waste/chemical management and containment.  Isolates infected patients.  Cleans patient contact areas and equipment according to policies and OSHA regulations.
• Promotes patient advocacy and confidentiality.

• Participates in ongoing nursing quality assurance program.
• Utilizes the Electronic Health Record (EHR) for documentation of clinical visits, interventions and screenings and assessments.
• Utilizes the care management platform for documentation of contacts, screenings and assessments and notifications.
• May be subject to on-call and callback.

• Demonstrates the ability to establish good interpersonal working relationships with patients and staff.
• Assists with and makes recommendations about supplies and equipment needs.
• Maintains clean, neat, and safe work environment.
• Demonstrates ability and willingness to adapt to special circumstances, such as, staffing shortages, patient emergencies, fluctuations in census, and disasters.
• The Licensed Practical Nurse provides care according to established procedures; under the supervision of the primary care provider.This is done under the supervision of the team‘s independent licensed practitioner.The work is evaluated for technical soundness and adherence to professional standards.

• May be necessary to work when Administrative leave is granted if patient care would be compromised.

Job Knowledge

• Knowledge of principles, practices, techniques, and theories of professional nursing in order to plan and provide nursing care to meet the physical, emotional, spiritual, and socio-cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2 years), Latency (6-9 years), Preadolescence (10-12 years), Early
• Adolescence (13-15 years), Adolescence (16-20 years), Adult (21-64 years), and Elderly
• (65-+ years).

• Knowledge and skill to perform basic clinical care to acute and chronically ill patients.

• Knowledge and skill to assist the primary care provider in treatment and examinations performed in the Outpatient setting.

 

• A practical knowledge of performing prescribed treatment plans such as dressing changes or soaks.
• Knowledge of proper handling and collection of specimens, performing vital signs and recognizing abnormal values.

• Basic knowledge of diseases and illnesses and the ability to recognize and report changes in the patient's condition to the physician.

 

• A practical knowledge of the medical facility's organization and services, the basic rules and regulations governing visitors and patient treatment, COBRA, and practical knowledge of standard procedures, medical records, and medical terminology.
• A basic knowledge of diseases, medical and surgical procedures, as well as standard abbreviations used by the medical staff.

• A thorough knowledge of recording and documenting medical information.
• Knowledge and skills in operating specialized medical equipment, such as suction pumps, oxygen equipment, etc.
• Applicant must have a valid North Carolina driver’s license.

Education, Licensure, Certification, and Experience

• Practical nursing diploma from an accredited program required. Two years of nursing experience preferred.

• Applicant must have an unrestricted valid Practical Nurse license within the state of North Carolina.

• Current Basic Life Support (BLS) is required of the position. Can be acquired within 6 months through the facility following appointment to position.
• 2 years’ experience preferred for the position.
• Proficiency rated at 6 weeks.

Complexity of Duties

The incumbent will be responsible for actively participating with a team of healthcare providers to provide and coordinate care. The incumbent will be expected to be positive and productive in the LPN role. The LPN role requires flexibility and the ability to work with team members who possess a variety of personalities. The LPN role necessitates the incumbent to always maintain a high level of integrity, poise, and control.

Supervision Received

The LPN plans, schedules, and provides care in coordination with the medical care plan and attempts to solve problems with MD/RN guidance. This is done under the supervision of the RN Lead and the Director of Nursing for Primary Care..  The work is evaluated for technical soundness and adherence to professional standards.

Responsibility for Accuracy

The incumbent has a positive effect upon the recovery of the patient and is responsible for following policies and procedures, which serve as hospital guidelines and prevents errors from occurring.  Errors can have a negative patient outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided.  Evaluations and observations are used to modify and develop clinically appropriate treatment plans.  Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent.

Contacts with Others

Contacts are with patients, families, hospital personnel, and community agencies.

Contacts with patients and families are to provide and assist with care.  With hospital personnel and community agencies, contacts are to exchange information for the purpose of coordinating patient care activities. The Nursing Assistant is assigned duties based upon the diagnosis of the patient, his/her condition, and special circumstances related to his/her needs.

Confidential Data

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical and personnel records and all other pertinent information that comes to the individual’s attention or knowledge.  The Privacy Act carries both civil and criminal penalties for unlawful disclosure of records.  Violation of such confidentiality shall be cause for adverse actions.

Mental/ Visual/ Physical

Work in the various services within the nursing department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers.  These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once. May occasionally move more than 15 pounds.

Environment

Must be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases. 

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.