Overall Purpose

The P3@Home Medical Assistant is a specialized, field-capable clinical support role that works exclusively within the P3@Home Program. This program delivers in-home primary care visits to patients who are homebound, bedbound, or chronically ill and unable to attend scheduled office visits. The primary goal of the program is to keep high-risk patients out of the emergency room and hospital by providing consistent, proactive medical care in the home setting.

The P3@Home MA serves as the operational backbone of the program, working closely with the P3@Home Nurse Practitioner to coordinate all aspects of patient care. This role requires a high degree of clinical knowledge, care coordination expertise, and compassionate communication, as patients and their families often depend on this individual as their primary point of contact for all medical and social needs.

Essential Functions

Scheduling & Chart Management

• Schedule all patient home visit appointments for the P3@Home Nurse Practitioner, coordinating around patient availability, acuity, and geographic routing.
• Create and maintain accurate, complete patient charts in the EMR (Athena) for all P3@Home patients, including demographic entry, insurance verification, and care history documentation.
• Perform thorough chart preparation prior to each visit, reviewing recent labs, imaging, specialist notes, medication lists, and outstanding care gaps to ensure the NP has complete information at the time of the visit.
• Document visit outcomes, care coordination activities, and follow-up actions in the EMR accurately and in a timely manner.

Care Coordination & Social Support

• Serve as the primary point of contact for P3@Home patients and their families, responding to calls and inquiries related to medical needs, appointments, referrals, and community resources.
• Coordinate at-home laboratory services, including scheduling mobile phlebotomy and ensuring results are routed to the NP for timely review and follow-up.
• Arrange home-based diagnostic imaging services as ordered by the NP.
• Coordinate referrals to and communication with home health agencies to ensure ordered services are initiated, authorized, and followed through.
• Facilitate durable medical equipment (DME) orders and delivery coordination, ensuring patients receive necessary equipment in the home.
• Connect patients and families with community resources, social services, transportation assistance, and other support programs as needed.
• Monitor and follow up on outstanding orders, referrals, and care coordination tasks to ensure nothing falls through the cracks between visits.

Clinical Support & Field Assistance

• Accompany the Nurse Practitioner on home visits as needed to provide clinical support, assist with procedures, obtain vital signs, and document care in real time.
• Assist with clinical tasks during home visits per scope and NP direction, which may include wound care support, specimen collection, or equipment operation.
• Maintain accurate supply inventory for the P3@Home program and coordinate restocking of clinical supplies used during home visits.

Transitions of Care & Hospital Follow-Up

• Monitor discharge reports and transitions of care notifications for P3@Home patients to ensure timely follow-up visits are scheduled post-hospitalization or post-ER visit.
• Coordinate with Nurse Case Managers, discharge planners, and home health agencies to facilitate smooth transitions back to home-based care.
• Proactively identify patients at elevated risk for readmission and escalate to the NP for expedited visits.

Communication & Collaboration

• Maintain professional, compassionate communication with patients, families, and caregivers, recognizing that this population is often medically complex, emotionally vulnerable, and highly dependent on support.
• Collaborate with clinic-based Practice Managers, Nurse Case Managers, Care Navigators, Referral Coordinators, and other P3 team members to ensure continuity of care for shared patients.
• Communicate with specialists, pharmacies, and external providers as needed to support patient care plans.
• Participate in team huddles, care management meetings, and program-level performance reviews.

Knowledge, Skills & Abilities

• Strong clinical knowledge base and understanding of chronic disease management, homebound patient populations, and preventive care.
• Proficiency in EMR systems (Athena preferred) including chart creation, documentation, scheduling, and referral management.
• Excellent care coordination skills with demonstrated ability to manage multiple patients, open tasks, and competing priorities simultaneously.
• Strong interpersonal and communication skills with patients, families, providers, and external agencies.
• Ability to function independently in the field with minimal supervision while maintaining high standards of documentation and follow-through.
• Knowledge of DME, home health, mobile lab, and imaging coordination processes.
• Familiarity with Medicare Advantage, managed care, and value-based care principles.
• Comfort with travel and the physical demands of field-based work, including transporting supplies and working in varied home environments.

Experience & Education

Required: High school diploma or GED; current Medical Assistant certification (CMA or RMA); 2+ years of clinical MA experience in a healthcare setting; strong experience with EMR documentation and patient scheduling.

Preferred: Experience working with homebound, geriatric, or medically complex patient populations; familiarity with home health, DME, or care coordination workflows; bilingual fluency in English and Spanish.

Pay Range: $20-25/hr depending on experience

About P3

People. Passion. Purpose. At P3 Health Partners, our mission is to guide communities to better health, unburden clinicians, align incentives, and engage patients. We are a physician-led organization committed to transforming healthcare from sickness care to wellness guidance. If you are passionate about making a difference, eager to grow, and thrive in a collaborative environment, we invite you to join our team.