Value Based Care Specialist

Key Responsibilities

• Track and coordinate follow-up care for patients discharged from hospitals and emergency departments using ADT (Admission-Discharge-Transfer) feeds and payer notifications
• Contact patients post-discharge to assess needs, reinforce discharge instructions, and schedule follow-up appointments with the Primary Care Provider (PCP) and internal services
• Ensure timely documentation of all transitional care activities and patient outreach in the electronic health record (EHR)
• Serve as a liaison between patients, internal care teams (PCPs, behavioral health, dental, pharmacy, care managers), and external providers (specialists, imaging centers, tertiary facilities)
• Monitor and report on value-based care quality metrics, including HEDIS, UDS, and payer-specific measures
• Use population health tools, registries, dashboards, and payer program portals to identify patients with care gaps, open orders, or overdue preventive screenings
• Participate in multidisciplinary team meetings, quality improvement committees, and external quality metric meetings
• Support administration for APCM, CCM, and RPM programs in accordance with requirements
• Document care coordination activities, patient communications, and service delivery to support accurate billing and compliance with CMS standards
• Support patient outreach to schedule follow-up, preventive care, and annual wellness visits
• Education patients on health center services and assist with internal referrals
• Ensure compliance with HIPAA/HITECH, CMS, HRSA, and other applicable requirements
• Follow standardized care management workflows, protocols, and documentation practices
• Create and update training materials for staff education on quality metric performance and program requirements
• Identify process improvement opportunities and participate in quality improvement initiatives
• Attend development activities to remain current on program requirements and best practices

Skills

• Strong communication, interpersonal, and customer service skills
• Attention to detail, especially data entry accuracy
• Strong organizational skills and ability to manage multiple priorities
• Knowledge of care coordination principles, transitions of care, and referral management
• Knowledge of value-based care concepts, including quality metrics (HEDIS, UDS, Star Ratings) and population health management
• Proficiency with electronic health records (EHRs), population health dashboards, payer program portals, and Microsoft Office Suite (especially Excel and PowerPoint)
• Ability to create training materials and educate staff on workflows and quality performance

Required Qualifications

• A High School Diploma or GED
• An active Registered or Certified Medical Assistant (RMA or CMA) certification
• Proficiency in use of electronic health records and Microsoft Office Suite
• Ability to work independently and as part of a multidisciplinary team

Preferred Qualifications

• Bilingual in English and Spanish or Marshallese
• 2+ years of experience in care coordination, quality improvement, or healthcare
• Familiarity with value-based care programs, CMS care management programs (APCM, CCM, RPM), and health risk stratification tools
• Experience with data reporting, quality metric tracking, or population health platforms