Care Coordinator

Position Summary:

We are seeking a dedicated and detail-oriented Care Coordinator to join our dynamic primary care team. This role is central to enhancing patient outcomes through effective care coordination, transition of care management, HCC gap closure, and value-based care initiatives. The ideal candidate will have prior experience as a Medical Assistant, strong familiarity with Epic EMR, and a passion for improving the patient experience and clinical quality metrics.

Key Responsibilities:

1. Transition of Care (TOC) Management

• Monitor and manage transitions from hospital to home or post-acute care settings.
• Conduct timely outreach to patients post-discharge (within 48 hours).
• Review discharge summaries, reconcile medications, and schedule follow-up appointments.
• Serve as liaison between patients, families, and providers to ensure smooth care transitions.

2. HCC (Hierarchical Condition Category) Gap Closure

• Identify and track patients with open HCC coding gaps and work with providers to address them.
• Review charts for accurate diagnosis coding and documentation to support risk adjustment.
• Educate clinical staff on HCC requirements and collaborate on coding best practices.

3. Value-Based Care Project Management

• Support and coordinate initiatives aimed at improving performance in value-based contracts (e.g., ACOs, MSSP, PCMH, Medicare Advantage).
• Monitor and report on quality metrics (e.g., annual wellness visits, preventive screenings, chronic condition management).
• Collaborate with population health teams to close care gaps and enhance patient engagement.
• Assist with data collection, dashboard tracking, and workflow optimization.

4. Medical Assistant

• Rooming patients, EKG’s, injections, assisting with minor surgeries, phone triage and call backs, chart documentation, and retrieving medical records.

Qualifications:

• Certified Medical Assistant (CMA) with a minimum of 2 years of clinical experience.
• Experience working in a primary care or outpatient clinical setting.
• Proficient in Epic EMR (documentation, reporting, chart review).
• Familiarity with care coordination principles and value-based care models.
• Strong organizational, communication, and interpersonal skills.
• Ability to manage multiple tasks, prioritize effectively, and work both independently and as part of a team.

Preferred Qualifications:

• Experience with quality improvement initiatives and risk adjustment strategies.
• Understanding of Medicare, Medicaid, and commercial value-based care programs.

Job Type: Part-time

Pay: $24.00 - $28.00 per hour

Expected hours: 24 per week

Benefits:

• 401(k)
• 401(k) matching
• Flexible schedule
• Paid sick time
• Paid time off
• Paid training
• Parental leave

Schedule:

• Choose your own hours

Ability to Commute:

• Bend, OR 97701 (Required)

Ability to Relocate:

• Bend, OR 97701: Relocate before starting work (Required)

Work Location: Hybrid remote in Bend, OR 97701

Salary : $24 - $28