Value Based Care Coordinator - Medical Assistant - Hybrid/Remote

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.

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

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-aced 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

Benefits

• Compensation commensurate with experience
• Medical, Dental, Vision Insurance
• 401K with Employer Match
• Health Savings Account Options
• Paid Holidays and PTO
• Referral Programs
• Short/Long Term Disability Insurance