Under the general supervision of the Manager, Ambulatory Care Navigation, this individual will support the Ambulatory Care Navigation Department through collaboration and coordination of transition of care activities. Responsibilities include medical record and report interrogation and audits; conducting outreach activities to post-acute facilities and patients for maximizing transitional care outcomes; facilitating post-facility discharge communication with patients, primary and specialty providers of care; enhancement of care delivery to maximize provider performance with value-based reimbursement and quality payment programs. Has working knowledge of policies, procedures, and protocols to assist with coordination projects and care navigation activities. 1. Performs detailed clinical data audits and ensures accuracy of patient data as assigned. 2. Audit, inspect, collect, and track clinical data related to quality and utilization metrics for value-based contracts and quality payment programs and initiatives. 3. Monitors and utilizes patient discharge lists, registries, and pursuit lists to facilitate the communication required to engage and educate patients, decreasing readmission rates back to the facility. 4. Conducts telephonic outreach methods to monitor discharge status and promote scheduled follow-up to close gaps-in-care for preventive and disease/condition-based services. 5. Identifies risk factors or barriers to care and makes appropriate notifications to the care team and/or referrals to disease management programs and community resources as needed. 6. Facilitates referral of complex patients to care navigation and other care coordination programs. 7. Assists as assigned with projects and audits designed to support and achieve system quality goals and objectives or to improve quality outcomes related to value-based reimbursement. 8. Supports care coordination transformation efforts through communication with staff and providers to make meaningful changes to their patient follow up in order to improve care delivery in the practice. 9. Establishes and maintains positive working relations with all key customers, physicians, office staff, patients, community resources, families and interdisciplinary teams and facilitates succinct communication to ensure an integrated team approach to achieve outcomes and other indicated deliverables. 10. Supports the ambulatory care navigation department in the gathering, assignment, and distribution of patient health information to facilitate the performance of Transitional Care Management activities. 11. Travel may be required. 12. Performs other duties as assigned. Education: High School Diploma or equivalent. Certified/registered medical assistant with a minimum of three years working in a physician’s office or related health care setting OR significant relative experience in a health care setting, required. Skills: Must demonstrate and promote a strong commitment to achieving customer satisfaction. Must be able to understand directions, communicate and respond to inquiries; requires effective interpersonal skills. Requires excellent verbal and written communication skills. Must demonstrate the ability to think and work effectively and accurately complete tasks within established deadlines. Must be able to work independently to solve problems and to prioritize tasks and deadlines. Strong computer skills, Microsoft applications, and EMR knowledge. Years of Experience: 3 years’ experience working in a physician’s office or related health care setting. License: N/A Certification: Certified/Registered Medical Assistant **Requisition ID:** 94804