Medical Assistant I (Non-Cert) 34 Mark West Springs General Surgery Limited Term

Sutter Health Santa Rosa , CA 95402

Posted 2 months ago

Sutter Pacific Medical Foundation is a not for profit corporation that exists to provide medical services, research and education. The foundation provides the infrastructure for the delivery of physician services, and contracts with a separate corporation comprised of physicians and other care providers to deliver the clinical services. This multi-specialty foundation will provide a platform from which new physicians can be recruited to continue to provide physician services in a nonprofit, community setting. The Foundation's vision is to create a medical group that will deliver high quality, market competitive medical services.

Under close to general supervision, works alongside providers, nurses, and other healthcare professionals in clinic offices to provide support services directly related to patient care.

Typical duties include taking patient histories and vital signs, collecting and performing routine tests on blood and other specimens, providing education and care instructions to patients, and assisting with simple procedures.

This role is an entry into the Medical Assistant job with the expectation that incumbents will become qualified to move into the next level within 12 months.

Patient Support

  • Prepares patients for appropriate exams/procedures by reviewing EHR health maintenance and disease management or patient chart for overdue or due-soon services; pends orders or initiates SmartSets, when appropriate.

  • Assists in patient education by providing informational pamphlet and after care instructions, and/ or after visit summary as instructed by the Clinician or according to Medical Foundation Policy.

Clinical Support

  • Performs tests, and collects/prepares specimens per written order or specific electronic order of the Clinician.

  • Having completed all required training, may apply and remove bandages and dressings; apply orthopedic appliances such as knee immobilizers, envelope slings, orthotics, and similar devices; remove casts, splints and other external devices; obtain impressions for orthotics, padding and custom molded shoes; select and adjust crutches to patient; and instruct patient in proper use of crutches.

  • Having completed all required training and deemed competent, may perform electrocardiogram, electroencephalogram or plethysmography tests, except full body plethysmography.


  • Rounds on patients.

  • Escalates service issues to supervisor/manager.

  • Huddles with providers to facilitate daily scheduling and make adjustments as necessary

Clinician Support

  • Gathers appropriate documents and signatures necessary to assist the Clinician in making treatment decisions, i.e. ABN forms, DPAHC, immunization consent.

  • Assists Clinician with EHR In-Basket management for prescription refills, results, authorizations/referrals and non-clinical secure e-Messages in accordance with Medical Foundation standards.

  • Assists the Clinician as necessary as a team member and employing lean techniques of smooth flow.

  • Receives and records lab/radiological test results (may include outside medical records) via telephone or computer and ensures that those results and related reports are with the patient's medical record at the time of the patient's visit.

  • May communicate normal test results only to the patient upon the direction of the Clinician.

  • Follows Medical Foundation policies and procedures for managing patient and pharmacy callbacks in a timely manner.

  • Relays Clinician instructions/orders to pharmacy (refills only without changes), patients, and other entities via computer, phone, fax, or mail.

  • Refers care outside of the Medical Assistant position to the appropriate licensed personnel.

Medication Management

  • May administer ordered medications orally, sublingually, topically, vaginally, rectally or by inhalation, with evidence of successful completion of formal competency verification.

  • Follows the 6 rights of safe medication administration; (1) Right individual (2) Right medication (3) Right dose (4) Right time (5) Right route (6) Right documentation

  • Follows Medical Assistant Medication Review Workflow approved by the Medical Foundation.

  • Performs medication review. Notes allergies as well as verifies medications patient is currently using. Medications patient has discontinued are recorded in visit notes. May not independently add or delete a medication from the medication list.

  • Medication reconciliation: The process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, and route and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points. This also includes removal of discontinued medications.


  • Ensures that exam rooms are clean, stocked, and appropriately set up each day prior to rooming patients.

  • Manages rooming and patient flow, including pre-visit preparation, assisting with the patient visit, and post-visit duties.

  • Escorts patient to the exam room within established time frame for department and is expected to communicate delays to the patient as appropriate. Follows all other Rooming Standards as established by the Medical Foundation.

  • Notifies patient of delays in accordance with Medical Foundation standards, giving him/her the option of rescheduling. Informs provider of schedule changes that impact patient flow.

Care of Medical Equipment and Maintenance Responsibilities

  • Cleans and sterilizes medical equipment as outlined by Medical Foundation policies and procedures, the manufacturer instructions, or by accepted procedures.

  • Maintains daily/weekly/monthly logs as required by appropriate regulatory agencies and Medical Foundation policies and procedures (i.e. autoclave, refrigerator/freezers, CLIA binder, etc).

  • Ensures that medical supplies are maintained at appropriate inventory levels.

  • Maintains the safety and integrity of medical equipment including inspecting the equipment for damage and/or the need for replacement of faulty equipment. Such faulty equipment must be reported to the appropriate person and removed from service.

  • Ensures the proper disposal of bio-hazardous and sharps waste.

  • Ensures all medication cabinets are locked according to Medical Foundation policies and procedures. Samples must be stored in a locked cabinet. For routine, non-controlled medication storage, the medications must be stored in a lockable cabinet. Routine medications should be in an area not readily accessible to non-staff.

Electronic Health Record (EHR) Documentation

Consistent with Medical Foundation policies and procedures, the Medical Assistant is allowed to perform the following tasks prior to the Clinician entering the exam room:

  • Obtain and document in EHR or paper chart complete and accurate vital signs (minimum of three), including blood pressure, pulse, respirations, temperature, weight, and height, appropriate for the patient's reason for visit. Medications being taken and allergies will also be documented at each visit.

  • Document exact quotes of patient's description of the chief complaint into the EHR. Those notes to be reviewed and signed off by the Clinician.

Once the clinician is in the exam room, the Medical Assistant can enter into the record verbal dictation from the Clinician and patient into the EHR (also referred to as "scribing").

Types of orders that may be pended:

  • A Medical Assistant may pend orders for lab, imaging tests, referrals, authorizations, DME and any other order class procedures found in the EHR for the Clinician to sign.
  • A Medical Assistant may not execute the orders until the Clinician has signed off in EHR.

Where paper charts are still in use:

  • Ensures that each page in the patient's medical record is labeled with the patient's name and date of birth.

  • Ensures that progress notes are labeled with the patient's name, date of birth, and date of service for each visit.

  • Files test results in the patient's medical record after Clinician signs off the results and gives appropriate instructions.

Other Job Functions

  • Scanning: When appropriate, document name and MRN on reports and send to scanning team.

  • Follows Medical Foundation policies and procedures for handling referrals.

  • Attends/participates in departmental meetings.

  • Follows all other relevant Medical Foundation policies and procedures for Medical Assistant role.

  • Schedule follow up appointments, when necessary, with patients while they are still in the exam room. Including direct scheduling into other specialty departments when necessary.


HS Diploma or equivalent education/experience is required.

Graduate of an accredited medical assisting program which includes a clinical externship required.

Proof of training in administering injections and performing skin tests, and/or training in venipuncture and skin puncture for the purpose of withdrawing blood, as required by California Medical Assisting Regulations is required.


Basic Life Support Certification

  • BLS is required upon hire.

Must receive certification as a Medical Assistant from an approved certifying organization as defined in Medical Assistant II within one year of hire.


Knowledge of basic anatomy and physiology.

Knowledge of medical terminology and abbreviations.

Knowledge and experience of universal precautions which is an approach to infection control to treat all human blood and certain body fluids as if they were known to be infectious for HIV, HBV, and other bloodborne pathogens (Bloodborne Pathogens Standard 29 CFR 1910.1030(b) definitions).

Knowledge and experience in medication administration.

Competent and validated in basic Medical Assisting skills such as taking vital signs, preparing patients for exam, and administering injections.

Basic computer and telephone skills.


  • Competent to excellent written and verbal communication skills, including accurate grammar, spelling and punctuation.

  • Demonstrated ability to communicate with a diverse group of patients.

  • Ability to recognize and respond to verbal and nonverbal communication


  • Special Skills
  • High performance expectation with the goal of providing an excellent experience for every patient and family member.

  • Teamwork and partnership skills to participate as a teammate with the Clinician and other team members.

  • AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) is a framework for employees to communicate with customers as well as with each other. Medical Assistants must be competent and validated in AIDET and other service excellence tools and tactics.

  • Dosage calculation skills as proven by successful completion of medication test and no less frequently than annual competency assessment.

  • Completes incident reports and notifies supervisor/manager.


  • Organizational skills and the ability to manage multiple tasks effectively, using lean techniques for standard work and smooth flow.

  • Computer skills including patient scheduling software and EHR.

  • Ability to efficiently operate office equipment, i.e. computer, telephone, fax, photocopy machine, etc.

  • Ability to establish priorities and coordinate work activities paying particular attention to detail.

  • The ability to manage multiple priorities and demands on time, while remaining calm.

Critical and Analytical Thinking:

Possess and apply logical problem solving skills.

Decision Making:

  • Duties and activities covered by specific instructions, standard practices, and established procedures that generally require little or no interpretation.

  • Requires limited decision making.

  • Knows when to ask for assistance.

  • Offers suggestions to solve basic problems in immediate work area.

Influencing and Leading:

Receives guidance and instruction from others.

Leadership and Professional Accountability:

  • Performs duties as assigned

  • Ensures that routine and priority tasks are completed within established timeframes.

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Medical Assistant I (Non-Cert) 34 Mark West Springs General Surgery Limited Term

Sutter Health