Medical Assistant Care Coordinator for Value Based Programs

Responsibilities

• Responsible for the Value Base Care clinical operations activities across the continuum of care.
• Provides health education, coaching and treatment decision support for patients.
• Collaborate with patient and interdisciplinary team members in assessing patient's needs.
• Conduct outbound calls to assess patients' current health status, identifying gaps or barriers in treatment plans.
• Provide patient education to assist with self-management.
• Provide patient care to patients as indicated in Program guidelines, including Program specific SDO’s.
• Attend daily team huddles and periodic informational huddles, meetings, patient conferences, or planning sessions.
• Evaluate payer and internal reports to identify physician and office trends.
• Build and develop collaborative relationships with assigned care centers to drive performance in Value Based Care Programs.
• Engage in patient EMR chart reviews to help close care gaps for a variety of payers and programs.
• Engage in multiple health plan/payer portals to submit supplemental data to close quality gaps.
• Collaborate effectively with internal teams to support care coordination for patients and drive metrics in Value Based Contracts.
• Make appropriate referrals to internal care team, payer programs, community resources, home care, and disease management programs.
• Maintain a panel/caseload of high-risk patients in collaboration with interdisciplinary team.
• Support and encourage patient usage of CommUnityCare's programs and services, including arranging appointments and additional services (e.g., transportation).
• Collaborate and coordinate care with Health plans, Community Organizations (CBOS), and patients primary care team.
• Contributes to the team decision-making process in planning daily priorities, and resolving barriers, and conflicts with action plans and creative solutions.

Qualifications

• MINIMUM EDUCATION: Graduate from an accredited medical assistant program
• REQUIRED CERTIFICATIONS/LICENSURE: Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current CPR certification during employment.