Community Clinic

General

• Track and coordinate follow-up care for patients discharged from hospitals and emergency departments
• Contact patients post-discharge to assess needs and schedule follow-up appointments
• Ensure timely documentation of all transitional care activities in the electronic health record (EHR)
• Serve as a liaison between patients, internal care teams, and external providers
• Monitor and report on value-based care quality metrics
• Use population health tools to identify patients with care gaps
• Support administration for APCM, CCM, and RPM programs
• Document care coordination activities, patient communications, and service delivery
• Conduct patient outreach to schedule follow-up visits
• Educate patients on health center services

Value Based Care Specialist