Value Based Care Specialist

Responsibilities Review patient charts and payer portals to identify care gaps. Contact patients directly to close care gaps and coordinate follow-up. Ensure medical records are updated with the most current and accurate quality metric information Maintain and monitor attribution lists to track patient assignments/panels. Collaborate with internal teams and external partners to align with best practices in population health. Maintain detailed spreadsheets and documentation to track outreach and outcomes. Support the development and implementation of processes that align with Value-Based Care goals. Assist in benchmarking efforts by connecting with FQHCs (Federally Qualified Health Centers) to mirror successful Population Health models. Program Coordination and Performance Management Serve as the primary liaison for payer value-based care (VBC) contracts, including Medicaid, Medicare, and commercial programs. Under the supervision of the Associate Director of Care Coordination and Special Programs Assists in monitoring the performance on quality and cost metrics (e.g., preventive screenings, chronic disease management, ED utilization, and patient engagement). Assists in developing and maintaining dashboards and assists with reports to track organizational performance against value-based care targets. Assists in collaboration with care teams to identify gaps in care and support outreach and intervention strategies. Participate in regular payer meetings and performance reviews, ensuring accurate reporting and timely submission of required data. Quality and Population Health Support Assists in partnering with Quality and Care Management teams to align value-based metrics with UDS, HEDIS, and NCQA-PCMH quality goals. Assists in supporting population health initiatives focused on preventive care, chronic disease management, and reducing health disparities. Assist in analyzing data to identify trends and opportunities for performance improvement. Assist in developing workflows and staff education to integrate value-based care principles into daily operations. Assist in facilitating communication between clinical teams, payors, and leadership regarding quality and cost-of-care initiatives. Data Management and Reporting Assists in working with the Data Analytics team to validate performance data and ensure accuracy of payer reports. Utilize the Electronic Health Record (EHR) and data platforms to run quality measure reports and identify patients needing interventions. Track incentive payments, performance bonuses, and financial outcomes associated with VBC contracts. Assist in preparing documentation and evidence for audits, payer reviews, and compliance activities. Collaboration and Education Assist in providing training and support to providers and staff on value-based care workflows, documentation, and coding best practices. Promote understanding of how clinical quality performance impacts payer contracts and financial sustainability. Assists in supporting interdepartmental collaboration to enhance care coordination, access, and patient satisfaction. Other duties as assigned. Performance Requirements Ability to recognize and respect cultural diversity of patients. Serve as the communication liaison between patient and physician. Capable of documenting patient communication and clinical treatment accurately and appropriately Recognize and respond effectively to verbal, nonverbal, and written communication. Ability to follow established policies and procedures dealing with health care Comply with established risk management and safety procedures. Able to establish and maintain effective working relationships with the public and health care team. Must respect the confidential nature of medical information and comply with HIPAA laws Working knowledge of standard concepts, practices, and procedures. Able to work efficiently and cope with emergency situations. Capable of using experience and judgment to plan and accomplish goals. Good computer skills and a working knowledge of Microsoft Office. Able to read and interpret documents such as charts, safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Behave in a professional manner and maintain a professional appearance. Must be a team player and always keep patients as the number one priority. Emotional and physical health sufficient to meet the demands of the position. Ability to stand/sit for long periods of time. Strength sufficient to lift some patients, move heavy equipment on wheels (up to approximately 250 lbs.), and to move patients in wheelchairs and stretchers. Consent to scheduled and random drug screen testing as required by NTACHC.