Why Join Care at Home?

Care at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Overview

The Practice Facilitator is a healthcare professional essential for guiding, coaching, and supporting Value-Based Payment Programs within medical practices. This role manages relationships with practice leadership and drives transformation in quality improvement and patient-centered care models. The Practice Facilitator focuses on improving clinical outcomes, streamlining operational workflows, and enhancing the total cost of care for populations by promoting best practices and integrating supportive care delivery models. Frequent travel to healthcare practices and community sites is required to ensure direct collaboration and on-site implementation support.

Key Responsibilities

Practice Support

• Facilitate understanding of value-based payment programs, such as ACOs, HEDIS, and Risk Scores.
• Present payor performance scorecards to review benchmarks and develop improvement strategies.
• Develop and provide quality improvement plans with tailored data, tools, and resources to support value-based care models.
• Obtain EMR access and provide support to close gaps in care and identify high-risk patients.
• Review high risk patients with providers, engage in high risk case management as needed, complete transitions of care as needed, and close quality gaps.

Quality Improvement

• Facilitate performance-based interventions with internal SMEs for HEDIS/STAR and risk adjustment benchmarks.
• Analyze practice-specific scorecards to identify trends and gaps and recommend improvements.
• Deliver education on ICD-10/CPT coding accuracy, risk adjustment, and population health management (e.g., TOC, AWVs, Diagnostic Attestation).
• Guide action plans using models like Plan-Do-Study-Act (PDSA) to drive care transformation and workflow efficiency.
• Monitor key performance indicators (KPIs) and medical loss ratio (MLR) to drive improvements in quality measures and total cost of care (TCOT).

Collaboration and Communication

• Build trust-based relationships with practices and care teams.
• Collaborate cross-functionally with internal departments and external stakeholders (e.g., IPAs, Providers, Payors).
• Act as a liaison between Care at Home and healthcare practices to ensure coordinated efforts.

Operational Excellence

• Act as an SME, supporting activities such as Transitions of Care (TOC), Pre-visit Planning, and Annual Wellness Visits (AWVs).
• Update and maintain internal and practice facing health data portals for quality tracking and reporting.
• Identify drivers of medical expenses and recommend remediation strategies.

General Duties

• Develop and maintain detailed project plans, tracking milestones, deadlines, and outcomes to ensure successful implementation of practice transformation strategies.
• Coordinate multiple projects simultaneously, managing priorities and resources effectively to meet the needs of diverse practices and stakeholders.
• Conduct scorecard analyses and develop action plans to enhance KPIs, including Quality, Risk Adjustment, Utilization, and practice growth metrics.
• Conduct regular check-ins with practices to ensure alignment with value-based care goals and identify emerging needs.
• Coordinate logistics for practice engagement meetings, including scheduling, agenda creation, and follow-up communications.
• Maintain up-to-date knowledge of healthcare regulations and value-based care models to provide relevant guidance to practices.
• Foster a culture of continuous improvement by encouraging regular feedback and promoting best practices across practices.
• Collaborate with leadership to identify opportunities for program enhancements and report on successes or challenges.
• Document workflows and processes to ensure standardization and facilitate onboarding or training for new staff.
• Actively participate in professional development opportunities to enhance skills related to quality improvement and practice transformation.
• Establish rapport with practice teams to facilitate effective communication and engagement.
• Provide regular updates to healthcare practices and Care at Home leadership on progress and challenges.
• Act as a resource for best practices in workflow optimization and care transformation.
• Participate in leadership meetings to share insights and build collaboration among stakeholders.
• Document all activities and insights related to practice operations in healthcare portals and team systems.
• Frequently travel to healthcare practices to support on-site implementation and coaching.
• Perform other job-related duties as assigned.

Required Qualifications

The Practice Facilitator should have the following qualifications:

Experience: Experience working in healthcare, preferably with quality improvement initiatives.

Education: Bachelor’s degree in Nursing, Unrestricted license in the state of practice

Skills:

• Strong communication and interpersonal skills to build trust and collaboration.
• Proficiency in Microsoft Office and electronic medical records (EMR).
• Knowledge of HEDIS, risk adjustment, and value-based care principles.
• Demonstrated ability to work effectively in a dynamic and collaborative environment.
• Ability and willingness to travel to practices and community sites as needed.
• Bilingual candidates are strongly preferred.

Our Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for Providers: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.

The working environment and physical requirements of the job include:

This position requires in-home, assisted living, and independent-living community based work. The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.

In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting or standing for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 50 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.