Practice Coordinator

Apex Health Solutions•Houston, TX

18h•Hybrid

About The Position

The Practice Coordinator performs advanced outreach and care coordination activities in support of value-based care initiatives. Operating primarily in the field, this role is responsible for conducting Annual Wellness Visit (AWV) and Transitional Care (TRC) outreach and scheduling, while also driving HEDIS gap closure through supplemental documentation collection and submission. The Practice Coordinator serves as a liaison between patients, providers, and the quality team, ensuring high-risk and hard-to-reach members receive timely preventive and transitional care services. This role supports field-based efforts in quality performance improvement across risk-bearing populations.

Requirements

Bachelor’s or Associate’s Degree in a related field, or three (3) or more years of equivalent healthcare outreach experience
Minimum 2–3 years of experience in patient outreach, care coordination, or community health, preferably in a managed care or value-based care setting
Demonstrated experience with AWV scheduling, TRC follow-up, or similar preventive care programs
Familiarity with HEDIS measures, supplemental data submission, and quality gap closure processes
Experience working in the field or conducting in-home patient visits preferred
Strong interpersonal and communication skills for engaging patients, families, and clinical staff
Ability to work independently in the field with minimal supervision
Demonstrated ability to manage a complex, high-volume caseload and prioritize effectively
Strong problem-solving skills to address barriers to care and escalate appropriately
Attention to detail in documentation, supplemental data, and record management
Ability to collaborate cross-functionally with quality managers, providers, and payer teams
Culturally competent and able to communicate effectively with diverse patient populations
Proficiency in Microsoft Office (Word, Excel, Outlook)
Working knowledge of Electronic Health Records (EHR); Epic and/or eClinicalWorks preferred
Familiarity with payer quality portals and supplemental data submission platforms
Ability to navigate care gap dashboards and population health tools

Nice To Haves

A license in one of the following is preferred: Pharmacy Technician (CPhT), Medical Assistant (CMA/RMA), Community Health Worker (CHW)
Knowledge of CMS STAR Ratings, risk adjustment (HCC/RAF), and NCQA requirements preferred

Responsibilities

Travels to clinics for in-field outreach to Medicare Advantage and other eligible members to schedule and facilitate Annual Wellness Visits (AWVs)
Performs Transitional Care (TRC) outreach following hospital discharge to support timely follow-up appointments and reduce readmissions
Schedules AWV and TRC appointments directly in the EHR (e.g., Epic, eCW) on behalf of patients and practices
Maintains accurate daily and weekly tracking of outreach attempts, scheduled visits, and completed appointments
Collaborates with centralized scheduling team
Identifies open HEDIS care gaps for assigned patient panels and prioritizes outreach based on measure deadlines and opportunity impact
Collects, organizes, and submits supplemental documentation (e.g., lab results, visit records, referral notes) to support measure closure with payers
Coordinates with provider offices and clinical staff to obtain missing documentation needed to close quality gaps
Works with Practice Performance Managers to track gap closure progress and flag unresolved barriers
Ensures all supplemental submissions meet payer specifications and timelines
Acts as a liaison between members, providers, and the quality team to facilitate timely and appropriate care access
Assists members with wraparound services including transportation arrangement, community resource connections, and appointment reminders
Conducts telephonic and in-clinic outreach to members at risk for care gaps, medication non-adherence, or care transitions
Refers members to case management, disease management, or social services as appropriate
Documents all outreach and coordination activities in the relevant system of record in a timely and accurate manner
Supports Practice Performance Managers with performance reporting, including tracking completion rates for AWVs, TRC visits, and HEDIS measures
Participates in weekly check-ins and monthly performance meetings to report on outreach progress and identify improvement opportunities
Assists in identifying workflow or operational barriers at the clinic level that affect quality outcomes
Completes special projects and assignments as directed by leadership
Performs other duties as assigned