The Value Based Care Specialist supports clinical outcomes and financial performance by coordinating patient care, managing care gaps, and documenting services in the EHR. They act as a liaison between internal care teams and external providers while monitoring quality metrics and supporting value-based care programs.
Requirements summary
Candidates must hold a high school diploma or GED and possess an active Registered or Certified Medical Assistant certification. Proficiency in electronic health records and Microsoft Office is required, with preference given to those with experience in FQHC settings and care coordination.
high schoolprofessional certificateComplianceMicrosoft Office SuiteHEDISCare coordinationPatient educationTransitions of careData entryProcess improvementUDSReferral managementClinical documentationElectronic health recordsPatient outreachStar ratingsPopulation health managementQuality metric performance
Job description
Community Clinic is a trusted regional healthcare system dedicated to delivering exceptional, whole-person care in a compassionate, professional, and welcoming environment.
As we continue to grow across the region, we remain grounded in one belief: people matter.
That includes our patients—and our team.
Every employee plays a vital role in living out our promise: We care.
You belong.
Job Summary
Community Clinic is seeking a Value Based Care Specialist to join our Quality team! This position is flexible on reporting location and can report to either location below:
Primary & Urgent Care location in Gentry, AR - 3rd St
Monday - Thursday 7:00 AM - 5:00 PM and Friday 7:00 AM - 12:00 PM.
Primary & Specialty Care location in Rogers, AR - Poplar St
Monday - Friday 8:00 AM - 5:00 PM
The Value-Based Care (VBC) Specialist plays a critical role in supporting the organization’s success under quality and value-based care models. This position is responsible for executing key functions across care coordination, quality metric performance, and reimbursable care management program support. Working within a Federally Qualified Health Center (FQHC) setting, the VBC Specialist proactively engages patients to close care gaps, coordinates transitions of care, supports enrollment and documentation for programs such as Advanced Primary Care Management (APCM), Chronic Care Management (CCM), and Remote Patient Monitoring (RPM), and monitors quality metrics to drive improved clinical outcomes and financial performance. An active Certified or Registered Medical Assistant certification is required.
Key Responsibilities
Track and coordinate follow-up care for patients discharged from hospitals and emergency departments using ADT (Admission-Discharge-Transfer) feeds and payer notifications
Contact patients post-discharge to assess needs, reinforce discharge instructions, and schedule follow-up appointments with the Primary Care Provider (PCP) and internal services
Ensure timely documentation of all transitional care activities and patient outreach in the electronic health record (EHR)
Serve as a liaison between patients, internal care teams (PCPs, behavioral health, dental, pharmacy, care managers), and external providers (specialists, imaging centers, tertiary facilities)
Benefits
Holidays
Health insurance
Dental insurance
Vision insurance
Paid time off
Employee discounts
Life insurance
403(b) retirement plan
Monitor and report on value-based care quality metrics, including HEDIS, UDS, and payer-specific measures
Use population health tools, registries, dashboards, and payer program portals to identify patients with care gaps, open orders, or overdue preventive screenings
Participate in multidisciplinary team meetings, quality improvement committees, and external quality metric meetings
Support administration for APCM, CCM, and RPM programs in accordance with requirements
Document care coordination activities, patient communications, and service delivery to support accurate billing and compliance with CMS standards
Conduct patient outreach to schedule follow-up, preventive care, and annual wellness visits
Educate patients on health center services and assist with internal referrals
Ensure compliance with HIPAA/HITECH, CMS, HRSA, and other applicable requirements
Follow standardized care management workflows, protocols, and documentation practices
Create and update training materials for staff education on quality metric performance and program requirements
Identify process improvement opportunities and participate in quality improvement initiatives
Attend development activities to remain current on program requirements and best practices
Skills
Strong communication, interpersonal, and customer service skills
Attention to detail, especially data entry accuracy
Strong organizational skills and ability to manage multiple priorities
Knowledge of care coordination principles, transitions of care, and referral management
Knowledge of value-based care concepts, including quality metrics (HEDIS, UDS, Star Ratings) and population health management
Proficiency with electronic health records (EHRs), population health dashboards, payer program portals, and Microsoft Office Suite (especially Excel and PowerPoint).
Ability to create training materials and educate staff on workflows and quality performance
Required Qualifications
High School Diploma or GED
Active Registered/Certified Medical Assistant (RMA or CMA)
Proficient in use of electronic health records and Microsoft Office Suite
Ability to work independently and as part of a multidisciplinary team
Preferred Qualifications
Bilingual in English and Spanish or Marshallese
2+ years of experience in care coordination, quality improvement, or healthcare.
Experience working in an FQHC, CHC, or similar safety-net healthcare setting
Familiarity with value-based care programs, CMS care management programs (APCM, CCM, RPM), and health risk stratification tools
Experience with data reporting, quality metric tracking, or population health platforms
Why Work at Community Clinic?
Be a part of a mission-driven organization committed to providing access to health-care to everyone in your community!
Excellent Benefits Package including:
Health, Vision, Dental and Life Insurance
403(b) Retirement plan (automatic employer contribution of 5% per paycheck!)
