Value Based Care Coordinator

White-Wilson Medical Center,P.A.•Fort Walton Beach, FL

7d•Onsite

About The Position

The Quality Value-Based Care (VBC) Coordinator supports population health and value-based care initiatives by managing patient outreach, organizing and prioritizing reports, scheduling care, and coordinating services across the continuum. This role focuses on closing care gaps, improving quality metrics, and supporting Transitional Care Management (TCM).

Requirements

Certified Medical Assistant (REQUIRED).
Minimum 1 year of prior medical/clinical experience preferred.
Experience in primary care, outpatient, or population health preferred.
Familiarity with EHR systems (e.g.,Athena) preferred.
Knowledge of value-based care, HEDIS measures, and Medicare Advantage is a plus.

Responsibilities

Review, sort, and prioritize value-based care reports (care gaps, risk patients, hospital discharges).
Identify and track patients needing preventive care and chronic disease management (HEDIS, Medicare Advantage, etc.).
Conduct outbound patient outreach (calls, messages) to schedule visits, screenings, and follow-ups.
Track daily hospital discharges and ER visits.
Perform post-discharge outreach within required timelines (e.g., 48 hours).
Schedule TCM visits within 7–14 days of discharge.
Support medication reconciliation and reinforce discharge instructions.
Coordinate follow-up care, referrals, and services to ensure continuity.
Schedule appointments aligned with care needs and quality initiatives.
Coordinate care between providers, specialists, and external services.
Educate patients on preventive care and provider care plans.
Identify barriers to care and escalate when necessary.
Serve as liaison between patients, providers, and health plans.
Review patient charts for missing or incomplete documentation.
Accurately organize and label documents within the HER.
Document all patient interactions, outreach, and coordination activities.
Maintain strict HIPAA compliance.
Utilize health plan portals and internal systems to track performance metrics.
Assist with audits, reporting, and quality improvement initiative.