Value based Care Coordinator - Agape Community Health

Position Summary

The Value-based Care Coordinator (VbCC) will facilitate Community Care Physician Network (CCPN) practice adoption and implementation of CCPN’s Quality Strategy to optimize practice performance in CCPN value-based care arrangements. The VbCC will be responsible for activities that help practices improve the health status and care for members attributed to CCPN’s Medicare Advantage, Medicaid, and Commercial health plans. The VbCC will be assigned to work on-site at one or more specific practices and will be accountable for furthering success in all areas of Population Health and Value-based Care. The Key function of the role is to coordinate with CCPN Quality Improvement and Provider Relations staff and other subject matter experts within CCPN and with practice providers and staff to assure implementation of and/or to develop strategies and workflows required to drive improvements in our 4 Keys to Success: optimizing care quality, improving care coordination, strengthening clinical documentation (risk adjustment), and improving clinical data integration to drive performance in value-based payment arrangements.

The VbCC will work directly with the practice staff to achieve these goals by tracking performance metrics, taking the lead in driving day-to-day workflow changes, and/or outreaching directly to members to schedule needed appointments, identify barriers, and connect practices with necessary supports within CCPN to ensure effective adoption of CCPN’s Quality Strategy.

Essential Functions

• Establish a supportive, effective, professional relationship with CCPN practices to facilitate behavior and system change to achieve improvements in health care quality.
• In accordance with CCPN’s Quality Strategy, work with the QIPS team and practice to utilize an evidence-based outcomes driven approach to assist the practice to manage and monitor performance on quality metrics and key performance indicators.
• Facilitate implementation of CCPN Quality Strategy within assigned CCPN Practice, includes assuring the following activities are in place:
  1. Use of Practice Perfect to assist the practice in achieving monthly performance targets, setting goals and monitoring progress, ensuring the CIN's quality measure workflows & priorities are followed to drive performance in our 4 Keys to Success: quality improvement, clinical documentation improvement/risk adjustment, care coordination, and reporting of clinical data.

Improved Health Care Quality:

• VbCC will manage and provide direct to member outreach and/or work with practice scheduling team to ensure scheduling of those on prioritized lists to improve health care quality.
• Work with CCNC’s Quality Improvement Specialists (QIS), Provider Relation Representatives (PRRs) and the practice staff to ensure the workflow of patient visits includes addressing of care gap and coding gap closure as specified in Practice Perfect Recommended Action, and helping practices develop necessary workflows and morning huddle functionality to ensure these strategies are adopted.

Care Coordination:

• Assuring practices are taking necessary steps to ensure access to care for attributed patients, providing necessary wellness visits to attributed patients each year, and providing timely follow up care for high-risk patients transitioning from the hospital or Emergency Department.
• VbCC will help trouble shoot where these systems are not working and work with QIPS team and others on workflow changes to adopt open-access scheduling and other solutions.
• VbCC will also lead efforts to establish a clear referral and communication process is established between CCPN and practice for patient referrals to complex care management team within CCPN and to ensure two-way communication between providers and care management team.

Clinical Data Improvement/Risk Adjustment:

• Ensuring CCPN’s clinical documentation improvement education and tools are incorporated in practice workflows, practices are aware of training opportunities, and connected with billing and coding specialists to help drive continuous improvement in clinical documentation of patient disease burden.

Clinical Data Reporting:

• Ensuring CCPN’s VIP strategies are optimized by coordinating with VIP team on EMR optimization for Health Jump (HJ) connections, ensuring lab and preventative screening results are recorded in correct location for HJ extraction, or necessary CPT II codes are dropped.
• To support the adoption of the Quality Improvement Plan, identify and coordinate when others are needed to coach and facilitate the use of standing orders, pre visit planning, team-based documentation, coding and documentation fundamentals, member engagement and outreach campaigns, annual wellness visit workflows, and other needs as identified by the practice, health plan or by CCPN.
• Effectively communicate business and technology issues as well as solutions.
• Escalate engagement and performance opportunities to manager and QIPS team promptly.
• Other duties as assigned.

Qualifications

• LPN, Medical Assistant (MA) certification, Associates, or bachelor's degree in a health-related field preferred. If Degree or completion of Medical Assistant certification, it must be from an accredited institution.
• If an LPN, current, active, unrestricted license to practice in North Carolina.
• Min 2–4-year experience in health care setting required and
• 1 year of value-based care and/or Population Health Experience

Knowledge, Skills, and Abilities

• Demonstrated understanding of value-based care principles, especially as they relate to Population Health management and improvement in health care quality.
• Solution oriented team member who can facilitate Population Health Initiatives within CCPN Network practices.
• Excellent communicator who can articulate the impact of population health initiatives with the practice and with their attributed members and their families.
• Knowledge of CCNC Quality Strategy, model of care management, population health, quality of care concepts, and health care delivery systems and their relation to Population health.
• Experience with direct to member outreach and care coordination activities such as scheduling appointments and education on the medical home and needed health care services.
• Experience with quality and process improvement methodologies and measures.
• Outstanding interpersonal skills and ability to demonstrate cooperation and teamwork.
• Accountable, self-starter with exceptional organizational and time management skills.
• Ability to serve as a change agent and stimulate innovative thinking.
• Excellent verbal and written communication skills, including presentations, meeting facilitation, and reports to present information clearly and concisely.
• Proficiency in Microsoft Office Suite.

Working Conditions

• The job environment is primarily embedded within one or more CCPN practices or the employee home environment.
• Routinely there may be some minor physical inconveniences or discomforts in the work setting, including sitting for moderate periods of time.
• Must be able to utilize office equipment, computer, keyboard, and phone with or without assistive devices.
• Repetitive wrist motion and occasional lifting/carrying of up to 25 pounds.
• Travel may be required within the region and/or the State.

The above statements are intended to describe the general nature and level of work performed in this position and are not to be construed as an all-inclusive list of duties, skills and responsibilities. In signing this job description, I confirm that I understand and am able to fulfill the terms of the position as set forth above.