Value Based Care Coordinator

Position Summary

• The Quality Value-Based Care (VBC) Coordinator supports population health and value-based care initiatives by managing patient outreach, organizing and prioritizing reports, scheduling care, and coordinating services across the continuum. This role focuses on closing care gaps, improving quality metrics, and supporting Transitional Care Management (TCM). Essential Responsibilities:
• Care Gap & Population Health Management: Review, sort, and prioritize value-based care reports (care gaps, risk patients, hospital discharges). Identify and track patients needing preventive care and chronic disease management (HEDIS, Medicare Advantage, etc.). Conduct outbound patient outreach (calls, messages) to schedule visits, screenings, and follow-ups.
• Transitional Care Management (TCM): Track daily hospital discharges and ER visits. Perform post-discharge outreach within required timelines (e.g., 48 hours). Schedule TCM visits within 7–14 days of discharge. Support medication reconciliation and reinforce discharge instructions. Coordinate follow-up care, referrals, and services to ensure continuity.
• Care Coordination & Patient Support: Schedule appointments aligned with care needs and quality initiatives. Coordinate care between providers, specialists, and external services. Educate patients on preventive care and provider care plans. Identify barriers to care and escalate when necessary. Serve as liaison between patients, providers, and health plans.
• Documentation & Chart Review: Review patient charts for missing or incomplete documentation. Accurately organize and label documents within the HER. Document all patient interactions, outreach, and coordination activities. Maintain strict HIPAA compliance.
• Health Plan & Quality Reporting: Utilize health plan portals and internal systems to track performance metrics. Assist with audits, reporting, and quality improvement initiative.

Education/Experience

Certified Medical Assistant (REQUIRED). Minimum 1 year of prior medical/clinical experience preferred. Experience in primary care, outpatient, or population health preferred. Familiarity with EHR systems (e.g.,Athena) preferred. Knowledge of value-based care, HEDIS measures, and Medicare Advantage is a plus.

Physical demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job responsibilities.