Value Based Care Specialist

Value Based Care Specialist

Community Clinic is a trusted regional healthcare system dedicated to delivering exceptional, whole-person care in a compassionate, professional, and welcoming environment. As we continue to grow across the region, we remain grounded in one belief: people matter. That includes our patients—and our team. Every employee plays a vital role in living out our promise: We care. You belong.

Community Clinic is seeking a Value Based Care Specialist to join our Quality team! The scheduled for this position is Monday - Friday 8:00 AM - 5:00 PM. The Value-Based Care (VBC) Specialist plays a critical role in supporting the organization's success under quality and value-based care models. This position is responsible for executing key functions across care coordination, quality metric performance, and reimbursable care management program support. Working within a Federally Qualified Health Center (FQHC) setting, the VBC Specialist proactively engages patients to close care gaps, coordinates transitions of care, supports enrollment and documentation for programs such as Advanced Primary Care Management (APCM), Chronic Care Management (CCM), and Remote Patient Monitoring (RPM), and monitors quality metrics to drive improved clinical outcomes and financial performance. An active Certified or Registered Medical Assistant certification is required.

Key Responsibilities

• Track and coordinate follow-up care for patients discharged from hospitals and emergency departments using ADT (Admission-Discharge-Transfer) feeds and payer notifications
• Contact patients post-discharge to assess needs, reinforce discharge instructions, and schedule follow-up appointments with the Primary Care Provider (PCP) and internal services
• Ensure timely documentation of all transitional care activities and patient outreach in the electronic health record (EHR)
• Serve as a liaison between patients, internal care teams (PCPs, behavioral health, dental, pharmacy, care managers), and external providers (specialists, imaging centers, tertiary facilities)
• Monitor and report on value-based care quality metrics, including HEDIS, UDS, and payer-specific measures
• Use population health tools, registries, dashboards, and payer program portals to identify patients with care gaps, open orders, or overdue preventive screenings
• Participate in multidisciplinary team meetings, quality improvement committees, and external quality metric meetings
• Support administration for APCM, CCM, and RPM programs in accordance with requirements
• Document care coordination activities, patient communications, and service delivery to support accurate billing and compliance with CMS standards
• Conduct patient outreach to schedule follow-up, preventive care, and annual wellness visits
• Educate patients on health center services and assist with internal referrals
• Ensure compliance with HIPAA/HITECH, CMS, HRSA, and other applicable requirements
• Follow standardized care management workflows, protocols, and documentation practices
• Create and update training materials for staff education on quality metric performance and program requirements
• Identify process improvement opportunities and participate in quality improvement initiatives
• Attend development activities to remain current on program requirements and best practices

Skills

• Strong communication, interpersonal, and customer service skills
• Attention to detail, especially data entry accuracy
• Strong organizational skills and ability to manage multiple priorities
• Knowledge of care coordination principles, transitions of care, and referral management
• Knowledge of value-based care concepts, including quality metrics (HEDIS, UDS, Star Ratings) and population health management
• Proficiency with electronic health records (EHRs), population health dashboards, payer program portals, and Microsoft Office Suite (especially Excel and PowerPoint).
• Ability to create training materials and educate staff on workflows and quality performance

Required Qualifications

• High School Diploma or GED
• Active Registered/Certified Medical Assistant (RMA or CMA)
• Proficient in use of electronic health records and Microsoft Office Suite
• Ability to work independently and as part of a multidisciplinary team

Preferred Qualifications

• Bilingual in English and Spanish or Marshallese
• 2+ years of experience in care coordination, quality improvement, or healthcare.
• Experience working in an FQHC, CHC, or similar safety-net healthcare setting
• Familiarity with value-based care programs, CMS care management programs (APCM, CCM, RPM), and health risk stratification tools
• Experience with data reporting, quality metric tracking, or population health platforms

Why Work at Community Clinic?

• Be a part of a mission-driven organization committed to providing access to health-care to everyone in your community!
• Excellent Benefits Package including:
• Health, Vision, Dental and Life Insurance
• 403(b) Retirement plan (automatic employer contribution of 5% per paycheck!)
• Paid Time Off and Holidays
• Employee Discounts for Care

Monday - Friday 8:00 AM - 5:00 PM 40 - Hours