Chronic Condition Management Program Assistant

The Program Assistant works under the direction of the CCM Manager and/or care/case managers to support the delivery and daily operations of CCM Population and care/case management programs. Support includes, but is not limited to, clerical duties, managing office logistics; facilitating communication with members, primary care team staff, and other departments and services, processing and maintaining databases, and maintaining program resources.

• Assists the CCM Manager or care/case manager in screening and enrollment of patients:


• May conduct population or care/case management program outreach efforts, using the system database or other outreach lists


• Obtains and reviews charts or other data related to ER visits and hospital admissions for follow-up and program enrollment


• Processes referrals received from electronic referral system


• Provides initial outreach to patients, introducing the care/case management program and processing of new referrals


• Sets up initial visits and/or classes as appropriate and mails out program materials


• Generates authorization letter when requested and follows up to ensure that written authorization is received if not electronically referred from primary care provider.


• Provides logistical support for classes, group visits and clinics:


• Schedules conference rooms


• Schedules patients


• Confirms schedule with providers and presenters


• Provides reminder calls/letters to patients


• Assists in preparing charts and supplies


• Assists patients in completing program questionnaire or log as needed


• Checks blood pressure, pulse, respirations, height, weight, peak flows, spirometry or downloads glucose meters as needed


• Registers members and generates OSCR forms per medical facility policy.


• Conducts visit registration and scheduling of  telephone and clinic visits:


• Schedules appointments


• Provides reminders as needed


• Coordinates or provides resources for patient-specific prevention activities


• Registers members for visits and generates OSCR forms per medical facility policy


• Processes referrals, schedule classes and follow-up appointments as directed by care/case managers


• Contacts overdue patients by phone or letter at direction of care/case managers.


• Maintains computer databases:


• Adds and delete patients into the Patient Alert System using program guidelines


• Manipulates and utilizes data in current patient population management report system.


• Enters patients in care/case management software programs and maintains data as appropriate, e.g. AmCare, Lotus Notes Case Management System, Cholesterol Management Program, MULTIFIT Program, etc.


• Maintains Access or Excel patient logs if used in conjunction with care/case management software applications.


• Manipulates and utilizes data to generate reports and queries as needed.


• Maintains daily program operations:


• Prepares, maintains and provides member packets for enrollment, group visits, classes and/or clinics


• Sends letters to patients and patients providers


• Makes copies of program materials, send faxes as needed


• Establishes and maintains a department filing system


• Answers phone and voice mail and routes messages to appropriate person; provides call backs to patients relaying responses from care/case manager


• Sorts and routes department mail


• Orders and transfers charts at the direction of care/case managers


• Sends memos and progress notes to patients MD/NPs


• Contacts patients by phone or by letter at direction of care/case managers for follow-up


• Upon program completion places patients on booking list for routine follow-up appointment with their primary care MD/NP per medical center policy


• Orders office and program supplies


• Works with care/case managers and other staff to maintain patient education resources, including inventory, ordering and distribution


• Communicates with Schedule Maintenance Department regarding care/case manager schedules.

Supervisory Responsibilities: This job has no supervisory responsibilities.

Grade 400