POSITION OVERVIEW:  

The M.A. / Specialty Care Coordinator functions as a core member of the Nutrition & Vaccine Departments as well as the Enhanced Care Management (ECM) & Medication Assisted Treatment (MAT) programs by working with FHCCGLA’s collaborative care teams to provide direct patient care support and administrative coordination (e.g., scheduling, productivity, patient contact efforts for follow-up, no-shows, etc.) to ensure efficient clinic operations and high-quality patient services. This role performs clinical M.A. duties, including patient intake, vital signs, medication and vaccine administration, and execution of provider orders.  

This position is specifically assigned the following Departments & Programs:

• Nutrition Department;
• Vaccine Department (backup);
• Enhanced Care Management (ECM); &
• Medication Assisted Treatment (MAT)

1. GENERAL M.A. DUTIES / RESPONSIBILITES:
2. Works in conjunction with FHCCGLA’s collaborative care team within each specialty to identify, initiate and implement measures to deliver the best high-quality care to patients and improve services.
3. Prepares patients for examinations and treatments.
4. Obtains and documents patient vital signs, medical histories, chief complaints, etc.
5. Performs patient intake and rooming procedures according to clinic protocols.
6. Maintains accurate and timely documentation in the Electronic Health Record (EHR).
7. Educates patients regarding medications, treatment plans, preventive care, and follow-up instructions.
8. Maintains infection control standards and ensure exam rooms and equipment are properly stocked and sanitized.
9. Monitors and reports patient concerns, abnormal findings, and urgent clinical issues to providers.
10. Coordinates scheduling and patient appointments.
11. Facilitates communication among providers, care teams, patients, and community partners.
12. Tracks referrals, authorizations, appointments, and program participation to ensure continuity of care.
13. Assists patients in accessing services and resources.
14. Monitors specialty department schedules, productivity metrics, appointment availability, patient volume, no-show rates, and referral completion to help ensure optimal program performance and utilization to support workflow efficiency.
15. Maintains accurate records and reporting related to coordinated programs.
16. Collaborates with the specialty teams to identify opportunities for improving patient access, scheduling efficiency, and overall productivity.

1. Undertakes continuous learning and growth opportunities by attending applicable trainings, seminars, conferences, in-services and educational sessions to maintain competency skill set current and remain knowledgeable with regards to best practices and industry standards of care.

17. Supports specialty services & program growth by conducting patient outreach, appointment reminders, follow-up calls, and care coordination activities aimed at increasing patient engagement, retention, and participation in treatment services.
18. Responds efficiently and timely to all patients and provider staff needs and inquiries.
19. Responds to emergencies to fill gaps as an M.A. at all sites when feasible and does not interfere with vaccine coordination activities (includes helping with vitals, EKG, ear lavage, pharmacy coverage, optometry, etc.)
20. Ensures excellent customer service to all FHCCGLA patients.

1. Participates in outreach activities within the surrounding communities (i.e. schools, health fairs, community organizations, etc.) in efforts to promote and increase immunizations. May include occasional evenings and weekends
2. Works with the operations managers to manage patient scheduling and flow to address bottlenecks, scheduling issues, etc.

23. Handles patient grievances according to FHCCGLA’s Policy & Procedures.

1. Assists in developing, updates & reviews of FHCCGLA Policies & Procedures (P&P’s) as needed (with input from all other key personnel).
2. Ensures HIPAA compliance by maintaining strict confidentiality of all patient data and E.H.R./Practice Management System (PMS) according to regulations and FHCCGLA’s P&P’s.
3. Tracks and reports productivity data to comply with FQHC coding requirements and Managed Care Plan auditing and billing specifications.
4. Attends/Participates in the following meetings/trainings:
1.  
2.  
3.  
4.  

28. Remains informed of:
    1. Current legal and regulatory changes related to scope of practice.
    2. Specific programs/payors, insurances accepted, and services offered at FHCCGLA.
    3. All applicable Policies & Procedures.

1. Travel is required to visit all FHCCGLA sites as needed.
2. All other duties as assigned (may be modified as business needs dictate).

1. Nutrition Related Duties / Responsibilities
   1. Follows and carries out provider orders and referral processes.
   2. Provides care coordination & clinical support
   3. Establishes a smooth internal workflow to seamlessly intake patient referrals into specific nutrition tracking cohorts (e.g., gestational diabetes or pediatric wellness programs).
   4. Records medical nutrition therapy (MNT) interventions, goal achievements, and social barriers to health within the EHR according to health center metrics.
   5. Tracks and reports data related to HRSA Uniform Data System (UDS) metrics, particularly focusing on adult/pediatric weight management and A1c tracking.
   6. Coordinates deliverables, collect metrics, and draft progress updates for nutrition-specific grants (e.g., HRSA quality grants, USDA programs, or local foundations).
   7. Conducts peer-led in-service training for medical assistants on basic nutritional screening tools and cultural competencies.
   8. Promotes current partnerships with local food banks, community-supported agriculture (CSA) initiatives, and "Food is Medicine" programs.
   9. Connects eligible patients directly with federal nutritional assistance programs like SNAP and WIC, actively reducing food insecurity barriers.
   10. Coordinates and facilitates group nutrition classes using low-literacy, multi-lingual, and culturally humble frameworks targeted to the clinic’s specific demographic.
   11. Performs proactive patient contact attempts regarding “no-shows”, and to follow-up and re-engage patients as needed.

1. Immunization Related Duties / Responsibilities
   12. Administers vaccines to both adults and children within their scope of practice and as ordered by FHCCGLA’s licensed medical providers.
   13. Follows and carries out provider orders, including laboratory, diagnostic, and referral processes.
   14. Serves as backup immunization coordinator for the Vaccine Department for all 6 FHCCGLA locations.
   15. Assists with vaccine scheduling & inventory tracking as needed.
   16. Ensures compliance related to vaccine storage, handling, and documentation requirements based on the following:
       1. Vaccines for Children (VFC) & Vaccines for Adults (VFA)- Staff can view a centralized summary of regional mandates on the EZIZ Hub:
          1. https://eziz.cdph.ca.gov/programs/vfc/requirements/ ; or
          2. https://eziz.cdph.ca.gov/programs/vfa/resources/
       2. Centers for Disease Control & Prevention (CDC)-

 https://www.cdc.gov/vaccines/hcp/storage-handling/index.html

• Health Resources & Services Administration (HRSA)- Evaluates operational site compliance, clinical quality, and health center program requirements for FQHCs.

1. CAIR - ensure Provider ID, Funding Source Code, Vaccine Eligibility Code, and NDC are documented accurately in CAIR, for every dose administered, to yield the most accurate data on the multi-line (vaccine) ordering form in myCAvax.
   1. https://www.cdph.ca.gov/Programs/CID/DCDC/CAIR/pages/cair-updates.aspx
   2. https://mycavax.cdph.ca.gov/s/
2. Etc.

17. Supports vaccine clinics and immunization initiatives as needed.
18. Supports, advises, updates, and trains clinical staff as necessary regarding:
    1. Vaccine updates.
    2. CAIR Software System.

• Missed opportunities.

1. Inventory control.
2. Vaccine storage and handling.
3. Supply Management (vaccines available/on hand, soon to expire, shortages, etc.).

• Goals.
• Temperature excursions

19. Develops and implements all immunization training, education, and clinical support activities for the agency.
20. Ensures all M.A. complete the necessary vaccine trainings at the time of hire and annually (review annual competency trainings).
21. Maintains records of all staff vaccine trainings (EZIZ, CAIR).
22. Ensures that all new, revised, or updated guidelines, forms and public health recommendations related to immunizations are distributed and implemented annually or as necessary- such as, but not limited to the Vaccine Information Statements (VIS)- https://www.cdc.gov/vaccines/hcp/current-vis/index.html
23. Ensures that accurate records are being maintained (through CAIR, logs, etc.) of all administered immunizations in order to generate accurate reports for FHCCGLA, VFC, VFA and/or other entities as required.
24. Serves as a backup liaison with local and state health departments regarding immunization initiatives and reporting requirements.
25. Consults with providers regarding the availability/shortage of vaccines, requirements and/or updates of the VFC Program and/or other grant funded programs as necessary.
26. Assists with immunization-related audits by ensuring all requirements are met (i.e., VFC, VFA, etc.).

1. ECM Related Duties / Responsibilities
2. Identifies and enrolls eligible high-risk patients (Populations of Focus) by meeting them in person where they are, including shelters, encampments, hospitals, or private homes.
3. Builds trust and cultivates strong relationships with marginalized patients using trauma-informed, culturally sensitive, and linguistically appropriate communication styles.
4. Educates patients and families about the voluntary nature of the ECM benefit, explain its value, and secure required program participation consents.
5. Performs related social needs assessments that capture clinical, behavioral health, physical/developmental, and social data.
6. Continuously monitor and update care plans based on the patient’s evolving clinical status or shifts in their social readiness to change
7. Serves as the single point of contact across the patient's entire interdisciplinary care team (PCPs, specialists, behavioral health providers, pharmacists, and community partners).
8. Coordinates access to other services inside and outside of FHCCGLA, assisting with appointment scheduling, check-ins, and reminders.
9. Manages complex patient transitions when individuals are discharged from high-acuity settings such as hospitals, emergency departments, skilled nursing facilities, or correctional facilities.
10. Executes timely follow-up protocols post-discharge to confirm the patient has necessary prescription refills, medical equipment, and immediate follow-up medical appointments scheduled
11. Connects patients to "Community Supports" and social service benefits, including housing navigation, disability application guidance, and utility assistance programs.
12. Addresses immediate food insecurity and mobility issues by arranging access to medically tailored meals and coordinating reliable medical transportation.
13. Coaches patients on lifestyle modifications and connect them to chronic condition support networks, smoking cessation tracks, or substance use recovery resources.
14. Performs proactive monthly contact attempts as needed to follow-up and re-engage patients as needed.

1. MAT Related Duties / Responsibilities
   27. Administers medications within their scope of practice and as ordered by FHCCGLA’s licensed medical providers.
   28. Follows and carries out provider orders, including laboratory, diagnostic, and referral processes.
   29. Assists providers during examinations and procedures as needed.
   30. Works closely with MAT providers and care teams to address barriers to treatment and improve patient adherence to care plans.
   31. Conducts initial patient screenings for substance use disorders using standardized clinical tools (such as the WAST, DAST, or COWS/CIWA scales) under clinical supervision.
   32. Assists new MAT patients with onboarding, orientation to the program, and explaining clinic agreements or treatment contracts.
   33. Assesses social determinants of health (SDOH) to identify barriers to treatment adherence, such as lack of transportation, unstable housing, or financial strain.
   34. Manages and tracks the MAT patient registry, scheduling regular follow-ups, induction appointments, and lab checks.
   35. Performs proactive follow-up contact attempts for all "no-shows" for missed MAT appointments to re-engage patients quickly.
   36. Coordinates external referrals for intensive outpatient programs (IOP), mental health counseling, residential treatment, or peer support groups.
   37. Educates patients on FDA-approved medications (e.g., buprenorphine/naloxone), proper storage, safety precautions, and the importance of taking medication as prescribed.
   38. Provides education on harm reduction models, overdose prevention, and the proper use/availability of Naloxone (Narcan).
   39. Serves as the primary, non-judgmental point of contact between the patient and the interdisciplinary care team (providers, behavioral health consultants, and case managers)
   40. Collects, processes, or tracks urine drug screens (UDS) and confirmatory lab work as ordered by the provider.
   41. Documents all patient interactions, care gaps closed, outreach efforts, and treatment plan progress accurately in the Electronic Health Record (EHR).
   42. Maintains strict adherence to confidentiality guidelines specific to substance use treatment, including federal HIPAA and 42 CFR Part 2 regulations.

MINIMUM QUALIFICATIONS:

1. High school diploma, minimum.

2. Current CPR Certification- required to be kept up-to-date.

1. M.A. Certificate, required

4. Minimum of 2 years of experience in healthcare, nursing, or public health setting

1. FQHC experience, highly preferred.

6. Prior experience or knowledge in the following departments, programs or services, preferred:

1. Motivation to take initiative to ensure all tasks performed are completed thoroughly and accurately.
2. Excellent writing and verbal communication skills.
3. Knowledge of administrative principles and procedures.

10. Computer knowledge a must (e.g., NextGen (E.H.R. & PMS)- preferred, Microsoft Word and Excel).
11. Bilingual English/Spanish and familiarity with the Hispanic culture.
12. Access to an automobile with valid California driver’s license and state mandated automobile insurance.
13. Ability to prioritize workload and work under pressure to meet tight, sensitive deadlines.
14. Motivated and committed to the provision of high-quality healthcare for indigent and underserved communities.
15. Willingness to adapt to changes with regard to the agency’s growth and expansion.

1. Ability to take initiative in performing and completing tasks.
2. Commitment to the provision of high-quality health care services and the goals and mission of Family Health Care Centers of Greater Los Angeles, Inc.
3. Willingness and ability to perform tasks in changing work environment.
4. Adaptability to program changes, modifications.

ADDITIONAL ELIGIBILITY QUALIFICATIONS:

1. Requires the ability to stand, walk, and lift vaccine supplies (carry/lift a minimum of ten pounds).
2. Must be willing/able to travel:
1. To perform job duties as needed
2.  For outreach activities and participation or coordination with partners.

3. Ability to work well with others in a professional and team-oriented environment.

1. Well-developed interpersonal skills, friendly personality and able to motivate staff by promoting teamwork.
2. Ability to relate to the public regardless of ethnicity, religion and economic status.

6. Excellent communication skills.

1. Strong planning and organizational skills.
2. Problem analysis and critical thinking skills.
3. Excellent customer service skills.
4. Knowledge of the following (but not limited to), preferred:

 VFC / VFA                      PPO’s                             HMO’s

 Medicare               Family PACT                   CPSP       

 Medi-Cal                        Fee-for-Service               CPE

 Managed Care Plans      Every Woman Counts