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Summary

The Care Management Administrative Assistant provides essential operational and administrative support to the SCHC Care Management team. Working under the direct supervision of the RN Care Manager III, this position keeps clinical workflows moving efficiently, from ADT alert intake and discharge follow-up scheduling through patient panel tracking, documentation support, and daily huddle coordination.

This role serves the full care management population regardless of payer, including Medicare, Medicaid, commercially insured, and uninsured patients. It supports the RN Care Managers, Patient Advocate Lead, Patient Advocates, and MIH Program Director in delivering timely, coordinated, and well-documented care across all active care management programs, including transitions of care, chronic care management, community health worker services, and the HUMS/MIH in-home touchpoint program.

The Care Management Administrative Assistant provides data gathering and reporting support as directed by the RN Care Manager III to assist with program monitoring, quality tracking, and compliance documentation. This position does not hold independent reporting accountability for value-based care or RHTP obligations.

The Care Management Administrative Assistant is responsible for performing the duties of the position during assigned workdays and scheduled work hours. Because several care management workflows require daily monitoring, timely follow-up, and same-day escalation, coverage for non-scheduled workdays will be supported by designated backup staff according to the Care Management coverage plan to ensure continuity of care management operations.

Essential Duties and Responsibilities

• ADT Alert Intake and Transitions of Care Tracking
  • Pull and triage overnight ADT alerts, including admits, discharges, and ED visits, from Athena Continuity of Care bucket and Azara TOC module each morning.
  • Log all discharge events in the TOC Care Group tracker; assign to RN Care Manager; note patient tier and follow-up priority.
  • Monitor active TOC episodes from ADT alert through follow-up visit completion; flag unresolved loops to RN Care Managers.
  • Track CMS-required 2-business-day interactive contact timelines; identify and escalate compliance gaps to RN Care Managers before end of business day.
  • Confirm discharge follow-up appointments are scheduled for all Tier 1 discharges before the end of the workday; coordinate with Patient Services as needed.
  • Prepare Monday morning discharge backlog summary for daily huddle, capturing all Friday and weekend discharges requiring same-day TOC contact.
• Scheduling Coordination & Workflow Calendar
  • Communicate patient tier risk levels to Patient Services at the start of each day and upon new ADT alerts to ensure tier-appropriate scheduling prioritization.
  • Coordinate scheduling for discharge follow-ups, chronic care management visits, telehealth encounters, and preventive care appointments per tier windows: Tier 1 = 24–48 hrs; Tier 2 = within 1 week; Tier 3 = 2–4 weeks.
  • Monitor scheduling gaps; escalate to Patient Services for same-day adds when clinically indicated by RN Care Manager.
  • Track appointment completion rates by tier; report no-shows to RN Care Managers within one business day using Sunshine’s no-show and cancellation reports.
  • Manage the CM team’s operational calendar: daily huddle schedule, reporting deadlines, quality review dates, and community outreach events.
  • Support coordination of interpreter services, transportation needs, and accessibility requirements with Patient Services.
  • Assist with care management outreach event logistics as directed: scheduling, patient notifications, resource materials, and post-event documentation.
• Patient Panel Tracking & Risk Monitoring
  • Maintain the active care management patient panel across all payers and risk tiers, including Tier P and Tiers 1–4, keeping tier assignments, open episodes, last contact dates, and next-step documentation current.
  • Monitor the panel for patients due for tier reassessment based on new utilization events, including hospitalizations, ED visits, and new diagnoses; flag for RN Care Manager review.
  • Ensure MIH outreach warm handoff documentation is received and acknowledged by the RN Care Manager; log handoff status in panel tracker.
  • Conduct patient outreach via Care Message for appointment reminders, care gap notifications, and preventive care prompts as directed by RN Care Manager III.
• Documentation & Follow-Up Support
  • Monitor open documentation tasks across the CM team; flag overdue visit notes, unsigned care plans, and missing required fields to the responsible clinician.
  • Support RN Care Managers with EHR documentation workflow by tracking completion status of required elements: SDOH screens, medication reconciliation, consent forms, and care plan completion.
  • Coordinate patient and community resource follow-up as directed by RN Care Manager III or Patient Advocate Lead; document all outreach attempts and outcomes in EHR same day.
  • Support referral tracking for SDOH referrals flagged from CM visits; confirm receipt with patient advocates for community partners and update status as directed.
  • Assist with CCM enrollment tracking: monitor patient consent documentation status and monthly service time thresholds for Medicare CCM-enrolled patients; report gaps to RN Care Manager III.
• Daily Huddle Facilitation & Team Communication
  • Facilitate or co-facilitate the daily CM team huddle; prepare the agenda each morning with ADT flags, new discharges, scheduling gaps, SDOH referral status, transportation gaps, VA authorization updates, and MIH handoff status.
  • Prepare the next-day huddle summary each afternoon with outstanding flags, tier re-stratification candidates, and open TOC items.
  • Distribute huddle summaries to RN Care Managers and relevant team members as directed.
  • Serve as a communication bridge across CM team roles, Patient Services, and Billing Team to maintain workflow continuity throughout the day.
• Data Gathering & Reporting Support
  • This position supports data collection and report preparation as directed by the RN Care Manager III. It does not hold independent reporting accountability.
  • Compile encounter data, care gap closure rates, TOC loop resolution rates, and other specified metrics as requested by RN Care Manager III for program monitoring purposes.
  • Assist with data gathering to support RHTP, MSSP quality measure tracking, UDS reporting, and monthly VBC outcome reporting preparation as directed and under the supervision of the RN Care Manager III.
  • Flag quality measure opportunities identified in panel data to the RN Care Managers for clinical review and action.
  • Maintain accurate records to support FQHC grant compliance and reporting obligations as directed.
• CM Resource, Equipment & Supply Management
  • Maintain the CM team’s library of patient-facing resource documents: community referral lists, self-management education materials, and SDOH resource guides; update as directed.
  • Ensure resource documents are current, accurate, and accessible to the full CM team.
  • Manage CM equipment and supply inventory: track stock levels, submit reorder requests, and coordinate distribution to RN Care Managers and MIH activities as needed.
  • Coordinate with appropriate departments for equipment maintenance or replacement.

Education and/or Experience

• High school diploma or equivalent required.
• Associate’s degree or higher in healthcare administration, business, or a related field preferred.
• Minimum 2 years of administrative or operational experience in a healthcare or clinical setting preferred.
• Experience working in a Federally Qualified Health Center, or FQHC, environment preferred.
• Experience with electronic health records in a clinical operations context; Athena One experience strongly preferred.
• Familiarity with population health or care management tracking tools; Azara experience preferred.
• Experience with patient outreach platforms such as Care Message or similar tools preferred.
• Exposure to care management programs, including CCM, TCM, transitions of care, or value-based care workflows at an operational level preferred.

General

To ensure the health of our community, patients, and staff, SCHC requires proof of completed vaccine series or serologic test results for MMR, Varicella, and Hepatitis B, as well as TB screening, prior to employment.