Senior Practice Facilitator #0733

About the role

The Practice Facilitator (RN/LPN) is a registered nurse OR licensed practical nurse who supports primary care practices participating in value-based payment programs by guiding, coaching, and enabling practice transformation efforts.

Responsibilities

• Facilitate understanding and implementation of value-based payment programs, including ACOs, HEDIS/STAR measures, and risk adjustment initiatives.
• Present payer and performance scorecards to review benchmarks, identify gaps, and develop/execute improvement strategies.
• Develop and support practice-specific quality improvement plans using tailored data, tools, and resources.
• Obtain EMR access and collaborate with practice teams to close gaps in care and identify high-risk patients.
• Facilitate performance-based interventions in collaboration with internal subject matter experts for HEDIS/STAR and risk adjustment benchmarks.
• Analyze practice-level data and scorecards to identify trends, gaps, and opportunities for improvement.
• Provide education and coaching on clinical documentation, ICD-10/CPT coding accuracy, risk adjustment, and population health management activities (e.g., Transitions of Care, Annual Wellness Visits, high-risk case management).
• Guide care transformation initiatives using structured, evidence-based improvement methodologies such as Plan-Do-Study-Act (PDSA).
• Monitor key performance indicators (KPIs), medical loss ratio (MLR), and total cost of care (TCOC) to support improved outcomes.
• Build and maintain trust-based relationships with practice leaders, clinicians, and care teams.
• Collaborate cross-functionally with internal departments and external stakeholders, interdisciplinary care team, Medical Director, Network Account Manager team, Quality leads, etc.
• Serve as a liaison between Grace at Home and healthcare practices to ensure alignment and coordinated execution of value-based initiatives relating to direct patient care.
• Act as a clinical subject matter expert supporting initiatives such as Transitions of Care (TOC), pre-visit planning, Care Management, Annual Wellness Visits (AWV)/preventative care completion and Voluntary Alignment (or other contract-driven growth initiatives)
• Conduct direct patient outreach on behalf of supported practices as needed to support care gaps, quality initiatives, and value-based program requirements.
• Perform chart abstraction, review, and data validation activities to support HEDIS and STAR measures, ACO and MSSP reporting requirements, risk adjustment initiatives, and internal or external audits.
• Prepare and support submission of required clinical and quality documentation to payers or internal teams.
• Develop and maintain project plans, including milestones, timelines, and outcomes, to support practice transformation initiatives.
• Manage multiple concurrent practice engagements while prioritizing resources effectively.
• Conduct regular check-ins with practices to assess progress, reinforce goals, and identify emerging needs.
• Cook up logistics for practice engagement meetings, including scheduling, agenda development, and follow-up.
• Maintain current knowledge of healthcare regulations, clinical quality standards, and value-based care models.
• Promote a culture of continuous improvement and adoption of best practices across supported practices.
• Document workflows, activities, and outcomes in designated systems and portals.
• Provide regular updates to leadership on progress, risks, and successes.
• Travel frequently to healthcare practices to support on-site implementation and coaching.

Qualifications

• Licensure: Active Registered Nurse or Licensed Practical Nurse (RN/LPN) license in good standing is preferred. Equivalent education or experience considered.
• Education: Bachelor of Science in Nursing (BSN) preferred; associate degree in nursing with relevant experience considered.
• Experience: REQUIRED: Experience working in a medical office setting, preferably primary care. Experience supporting quality improvement initiatives, population health, or value-based care programs. Training or experience in root cause analysis and development of quality improvement plans. Experience leading or supporting initiatives within interdisciplinary clinical teams. Training or experience in EMR analytics/development a plus.
• Skills: Strong communication, coaching, and interpersonal skills to build trust and collaboration with clinical teams. Proactive professional who can take strategic direction and work with autonomy, creativity, and accountability, moving initiatives from concept to full execution. Proficiency in Microsoft Office and electronic medical record (EMR) systems. Knowledge of HEDIS/STAR measures, risk adjustment, and value-based care principles. Ability to analyze data and translate insights into actionable practice improvements. Ability and willingness to travel frequently to practices and community sites. Bilingual candidates strongly preferred.