Medical Assistant Care Coordinator for Value Based Programs

## Overview Reporting to the Manager for Value Based Care Programs (MVBCP), the Medical Assistant -Care Coordinator (MACC) will provide key interventions as defined in CommUnityCare’s Value-Based Program. The positions will ensure effective management of performance metrics, care coordination, management of care gaps, patient outreach to schedule patients for appointments, and quality measure attestations ## Responsibilities **Primary Accountabilities:**• Responsible for the Value Base Care clinical operations activities across the continuum of care from assessing, implementing, coordinating, monitoring, and evaluating.• Provides health education, coaching and treatment decision support for patients.• Collaborate with patient and interdisciplinary team members in assessing patient's needs.• Conduct outbound calls to assess patients' current health status, identifying gaps or barriers in treatment plans.• Provide patient education to assist with self-management.• Provide patient care to patients as indicated in Program guidelines, including Program specific SDO’s• Attend daily team huddles and periodic informational huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the Value Based Program efforts.• Evaluate payer and internal reports to identify physician and office trends.• Build and develop collaborative relationships with assigned care centers to drive performance in Value Based Care Programs.• Engage in patient EMR chart reviews to help close care gaps for a variety of payers and programs.• Engage in multiple health plan/payer portals to submit supplemental data to close quality gaps.• Collaborate effectively with internal teams to support care coordination for patients and drive metrics in Value Based Contracts.• Make appropriate referrals to internal care team, payer programs, community resources, home care, and disease management programs.• Monitor all VBC projects ensuring that these projects stay on schedule.• Support patient experience initiatives designed to improve provider star rating.• Initiate pre-charting efforts to address overdue health maintenance.• Update and maintain patient data to assist in the assigning of patient risk scores. • Assist in completing social determinants of health questionnaire and My Chart activations.• Improve communication between patient and health care providers.• Support patients using a comprehensive, chronic care management model of care.• Increase patient’s knowledge of medical conditions and improve self-management practices.• Coordinate with internal and external social services agencies and programs to ensure that patient receives needed services.• Support patients to increase medical compliance, improve health outcomes, and increase their self-report quality of life.• Maintain a panel/caseload of high-risk patients in collaboration with interdisciplinary team.• Support and encourage patient usage of CommUnityCare’s programs and services, including arranging appointments and additional services (e.g., transportation).• Collaborate and coordinate care with Health plans, Community Organizations (CBOS), and patients primary care team.• Contributes to the team decision-making process in planning daily priorities, and resolving barriers, and conflicts with action plans and creative solutions.• Demonstrates initiative and flexibility in working with intra / interdisciplinary teams.• Actively shares knowledge and information with team members.• Train and orient new employees. • Complete other duties as assigned. **Knowledge/Skills/Abilities:**• Effective level of skill at building relationships and providing excellent customerservice.• Requisite skills and ability to perform certain medical tasks as assigned.• Strong attention to detail and accuracy.• Ability to utilize computers for data entry and information retrieval.• Demonstrates effective written and communication skills.• Strong…