Value Based Care Coordinator- Medical Assistant- Hybrid/Remote

Catalyst Physician Group•Plano, TX

1d•Hybrid

About The Position

The Value-Based Care Coordinator supports primary care clinics by executing standardized workflows that drive value-based care performance across Commercial and Medicare populations. This role focuses on patient outreach, scheduling, care gap closure support, and provider workflow preparation to ensure patients are connected to care and providers are equipped to address quality and risk opportunities during visits.

Requirements

LVN, Certified Medical Assistant, or equivalent clinical experience required
2-4 years of experience in a clinical or physician office setting
Experience with EMR systems (Athena preferred)
Strong organizational and communication skills
Ability to manage multiple priorities in a fast-paced environment

Nice To Haves

Experience in value-based care, quality, HEDIS, or care coordination workflows
Experience with patient outreach and population health initiatives
Familiarity with Medicare and Commercial value-based programs

Responsibilities

Conduct targeted outreach to patients to support completion of recommended care including: Annual Wellness Visits, Preventive screenings (e.g., mammogram, colorectal cancer screening), Chronic disease follow up (A1C, blood pressure checks)
Prioritize outreach to high-risk, high-opportunity, and care gap populations
Schedule appointments and coordinate folow-up to support timely completion of care
Document outreach and scheduling activities in the EMR
Identify patients with open care gaps using available reports and tools
Support closure of care gaps by scheduling required services and coordinating with clinic teams and referral partners
Track completion of recommended services and update systems accordingly
Prepare and ensure availability of tools that support provider performance at the point of care including: BOI/diagnosis capture forms, Encounter plans and clinical pathway tools
Support pre-visit planning by identifying outstanding care gaps and relevant patient needs
Ensure information is accurate and available to reduce missed opportunities during visits
Execute workflows that support: Quality measure reporting and submissions (HEDIS / Star), Attestations / MIPs and required documentation processes
Support provider documentation readiness through standardized workflows (e.g., BOI preparation)
Reconcile labs/imaging, consults, and externa records to ensure information is available for complete and accurate documentation
Coordinate follow-up care, referrals, and diagnostic testing as needed
Communicate with patients, providers, and clinic staff to support continuity of care
Assist with clinical program enrollment and follow-up activities
Maintain assigned work queues, inboxes, and reports
Follow standardized workflows and escalate issues or barriers as appropriate
Provide cross-coverage for team members as needed
Participate in team meetings and ongoing training