Value Based Care Coordinator/CMA/Remote

Position Summary: 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). Essential Responsibilities: Care Gap & Population Health Management: 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. Transitional Care Management (TCM): 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. Care Coordination & Patient Support: 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. Documentation & Chart Review: 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. Health Plan & Quality Reporting: Utilize health plan portals and internal systems to track performance metrics. Assist with audits, reporting, and quality improvement initiative. Education/Experience: 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. PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job responsibilities. While performing the duties of this job, the employee is occasionally required to stand; walk; sit for extended periods of time; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, bend, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 40 pounds. Repetitive motion of upper body is required for extended use of computers and phones. Required specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Position Type/Expected Hours of Work: This is a full-time position in an outpatient medical business office setting. Days and hours of work are Monday through Friday between the hours of 8:00am to 5:00pm. Based on business need, the ability to work a flexible schedule, including some overtime as approved in advance. WORK ENVIRONMENT: The work environmental characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job responsibilities. Works in a well-lit, ventilated and climate-controlled office environment with routine office equipment; some equipment has moving mechanical parts. Noise level in the work environment is usually quiet to moderate. Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. EEO Statement: White-Wilson Medical Center, P.A. and affiliates are equal opportunity employers, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.