Overview Value Based Care Coordinator role at Tapestry 360 Health. The Value Based Care Coordinator plays a critical role in improving patient outcomes and supporting value-based care and payment metrics. This position manages hospital admission, discharge, and transfer processes and ensures seamless coordination of care for patients transitioning from hospital to home or other care settings. The role involves assisting with projects, initiatives, and outreach to support achieving performance in accordance with value-based contracts.
Responsibilities Oversee the admission, discharge, and transfer processes to facilitate smooth transitions for patients.
Obtain patient records/summaries and ensure timely follow-up appointments with PCPs are scheduled.
Collaborate with hospital care managers and outreach to patients while hospitalized.
Collaborate with healthcare teams to ensure follow up and continuity of care during transitions from inpatient to outpatient care.
Act as a liaison between patients, families, healthcare providers, and community resources.
Coordinate patient entry into T360H health centers.
Monitor high-cost, high-utilizer patient lists to engage and encourage appointments with care team members.
Engage non-established patients, schedule appointments, and assist with PCP changes.
Review insurance-supplied patient and reattribution lists for accuracy.
Monitor attribution lists from managed care organizations for proper coordination of care.
Participate in quality improvement and empanelment initiatives.
Conduct outreach and education to targeted patient populations to help close care gaps.
Other duties as assigned.
Qualifications High school diploma or equivalent required; Associate's or Bachelor's degree preferred; education in Medical Assisting or another healthcare-related field preferred.
Experience in hospital care coordination, case management, or related healthcare roles.
Working knowledge of EMR systems preferred.
Microsoft Office experience (including Excel) preferred.
Bilingual in Spanish preferred.
Strong understanding of healthcare systems and patient care transitions.
Excellent communication and interpersonal skills, ability to collaborate and clearly document work.
Physical Demands and Work Environment Primarily office-based with some on-site hospital and health center visits. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Salary and Benefits The annual salary range for this position is $45,000 to $55,000 based on experience and qualifications.
Comprehensive benefits package including health and dental insurance, retirement savings plans, paid time off, and continuing education. This position may be eligible for the Federal Public Service Loan Forgiveness (PSLF) program.
How to Apply Interested candidates should visit the Tapestry 360 Health website to explore career opportunities and submit an application. Apply online at www.tapestry360health.org/careers.
Equal Employment Opportunity Tapestry 360 Health is an equal opportunity employer. We comply with applicable laws and maintain equitable and transparent pay practices. This includes disclosures under applicable pay transparency acts. We reserve the right to revise or change job duties as needed. This description does not constitute a contract.