SUMMARY:

The Practice Coordinator performs advanced outreach and care coordination activities in support of value-based care initiatives. Operating primarily in the field, this role is responsible for conducting Annual Wellness Visit (AWV) and Transitional Care (TRC) outreach and scheduling, while also driving HEDIS gap closure through supplemental documentation collection and submission. The Practice Coordinator serves as a liaison between patients, providers, and the quality team, ensuring high-risk and hard-to-reach members receive timely preventive and transitional care services. This role supports field-based efforts in quality performance improvement across risk-bearing populations.

EDUCATION:

•        Bachelor’s or Associate’s Degree in a related field, or three (3) or more years of equivalent healthcare outreach experience

LICENSES/CERTIFICATIONS:

A license in one of the following is preferred:

•        Pharmacy Technician (CPhT)

•        Medical Assistant (CMA/RMA)

•        Community Health Worker (CHW)

EXPERIENCE:

•        Minimum 2–3 years of experience in patient outreach, care coordination, or community health, preferably in a managed care or value-based care setting

•        Demonstrated experience with AWV scheduling, TRC follow-up, or similar preventive care programs

•        Familiarity with HEDIS measures, supplemental data submission, and quality gap closure processes

•        Experience working in the field or conducting in-home patient visits preferred

•        Knowledge of CMS STAR Ratings, risk adjustment (HCC/RAF), and NCQA requirements preferred

SKILLS:

•        Strong interpersonal and communication skills for engaging patients, families, and clinical staff

•        Ability to work independently in the field with minimal supervision

•        Demonstrated ability to manage a complex, high-volume caseload and prioritize effectively

•        Strong problem-solving skills to address barriers to care and escalate appropriately

•        Attention to detail in documentation, supplemental data, and record management

•        Ability to collaborate cross-functionally with quality managers, providers, and payer teams

•        Culturally competent and able to communicate effectively with diverse patient populations

RESPONSIBILITIES:

In-Field AWV and TRC Outreach & Scheduling:

•        Travels to clinics for in-field outreach to Medicare Advantage and other eligible members to schedule and facilitate Annual Wellness Visits (AWVs)

•        Performs Transitional Care (TRC) outreach following hospital discharge to support timely follow-up appointments and reduce readmissions

•        Schedules AWV and TRC appointments directly in the EHR (e.g., Epic, eCW) on behalf of patients and practices

•        Maintains accurate daily and weekly tracking of outreach attempts, scheduled visits, and completed appointments

•        Collaborates with centralized scheduling team

HEDIS Gap Closure & Supplemental Documentation:

•        Identifies open HEDIS care gaps for assigned patient panels and prioritizes outreach based on measure deadlines and opportunity impact

•        Collects, organizes, and submits supplemental documentation (e.g., lab results, visit records, referral notes) to support measure closure with payers

•        Coordinates with provider offices and clinical staff to obtain missing documentation needed to close quality gaps

•        Works with Practice Performance Managers to track gap closure progress and flag unresolved barriers

•        Ensures all supplemental submissions meet payer specifications and timelines

Member Advocacy & Care Coordination:

•        Acts as a liaison between members, providers, and the quality team to facilitate timely and appropriate care access

•        Assists members with wraparound services including transportation arrangement, community resource connections, and appointment reminders

•        Conducts telephonic and in-clinic outreach to members at risk for care gaps, medication non-adherence, or care transitions

•        Refers members to case management, disease management, or social services as appropriate

•        Documents all outreach and coordination activities in the relevant system of record in a timely and accurate manner

Quality Support & Reporting:

•        Supports Practice Performance Managers with performance reporting, including tracking completion rates for AWVs, TRC visits, and HEDIS measures

•        Participates in weekly check-ins and monthly performance meetings to report on outreach progress and identify improvement opportunities

•        Assists in identifying workflow or operational barriers at the clinic level that affect quality outcomes

•        Completes special projects and assignments as directed by leadership

•        Performs other duties as assigned

TECHNICAL SKILLS:

•        Proficiency in Microsoft Office (Word, Excel, Outlook)

•        Working knowledge of Electronic Health Records (EHR); Epic and/or eClinicalWorks preferred

•        Familiarity with payer quality portals and supplemental data submission platforms

•        Ability to navigate care gap dashboards and population health tools