Identify and track care gaps related to quality measures (e.g., Healthcare Effectiveness and Data Information Set (HEDIS), STAR, value-based metrics)
Support clinic efforts to meet value-based performance goals through proactive patient outreach and follow-up
Maintain patient registries and dashboards to monitor quality, utilization, and outcomes
Assist with population health initiatives targeting high-risk or high-utilization patients
Patient Outreach & Care Coordination:
Conduct outreach to patients to schedule appointments, screenings, labs, and follow-up visits
Educate patients on the importance of preventive services, wellness visits, and care plan adherence (non-clinical education only)
Assist patients with navigation of clinic services, community resources, and health system processes
Data, Documentation & Reporting:
Enter and update quality and care coordination data in electronic health records and quality platforms
Validate documentation to ensure accuracy and completeness for quality reporting
Support chart reviews, audits, and gap-closure workflows
Prepare reports and summaries for clinical and quality leadership
Collaboration & Clinic Support:
Work collaboratively with providers, nurses, medical assistants, front-desk staff, and quality teams
Participate in huddles, quality meetings, and performance improvement initiatives
Communicate care gaps and patient needs clearly to clinical team members
Support standardization of workflows related to quality and value-based care
Qualifications:
Education/Experience:
High school diploma or equivalent
Minimum of 2 years of experience in a healthcare setting (outpatient, ambulatory, managed care, or population health preferred)
Certified Medical Assistant (CMA) license OR associate's or bachelor's degree in healthcare, public health, health administration, or related field (preferred)
