Practice Facilitator (RN)

Why Join Grace at Home?

Grace 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 (RN) is a registered nurse who supports primary care practices participating in value-based payment programs by guiding, coaching, and enabling practice transformation efforts. This role partners closely with practice champions and care teams to improve clinical quality, patient-centered care delivery, operational workflows, and total cost of care for defined populations.

The Practice Facilitator focuses on implementing evidence-based quality improvement strategies, supporting population health initiatives, and integrating value-based care best practices within clinical workflows. This is a field-based role that requires frequent travel to primary care practices and community sites to provide hands-on, on-site support and collaboration.

Duties & Responsibilities

• Practice Support
  • Facilitate understanding and implementation of value-based payment programs, including ACOs, HEDIS/STAR measures, and risk adjustment initiatives.
  • Present payer and performance scorecards to review benchmarks, identify gaps, and develop improvement strategies.
  • Develop and support practice-specific quality improvement plans using tailored data, tools, and resources.
  • Obtain EMR access and collaborate with practice teams to close gaps in care and identify high-risk patients.

• Quality Improvement

  • Facilitate performance-based interventions in collaboration with internal subject matter experts for HEDIS/STAR and risk adjustment benchmarks.
  • Analyze practice-level data and scorecards to identify trends, gaps, and opportunities for improvement.
  • Provide education and coaching on clinical documentation, ICD-10/CPT coding accuracy, risk adjustment, and population health management activities (e.g., Transitions of Care, Annual Wellness Visits, diagnostic attestation).
  • Guide care transformation initiatives using structured improvement methodologies such as Plan-Do-Study-Act (PDSA).
  • Monitor key performance indicators (KPIs), medical loss ratio (MLR), and total cost of care (TCOC) to support improved outcomes.

• Collaboration & Communication

  • Build and maintain trust-based relationships with practice leaders, clinicians, and care teams.
  • Collaborate cross-functionally with internal departments and external stakeholders, interdisciplinary care team, Medical Director, Network Account Manager team, etc.
  • Serve as a liaison between Grace at Home and healthcare practices to ensure alignment and coordinated execution of value-based initiatives.

• Operational Excellence

  • Act as a clinical subject matter expert supporting initiatives such as Transitions of Care (TOC), pre-visit planning, and Annual Wellness Visits (AWVs).
  • Conduct direct patient outreach on behalf of supported practices as needed to support care gaps, quality initiatives, and value-based program requirements.
  • Perform chart abstraction, review, and data validation activities to support HEDIS and STAR measures, ACO and MSSP reporting requirements, risk adjustment initiatives, and internal or external audits.
  • Prepare and support submission of required clinical and quality documentation to payers or internal teams.

• General Duties

  • Develop and maintain project plans, including milestones, timelines, and outcomes, to support practice transformation initiatives.
  • Manage multiple concurrent practice engagements while prioritizing resources effectively.
  • Conduct regular check-ins with practices to assess progress, reinforce goals, and identify emerging needs.
  • Coordinate logistics for practice engagement meetings, including scheduling, agenda development, and follow-up.
  • Maintain current knowledge of healthcare regulations, clinical quality standards, and value-based care models.
  • Promote a culture of continuous improvement and adoption of best practices across supported practices.
  • Document workflows, activities, and outcomes in designated systems and portals.
  • Provide regular updates to leadership on progress, risks, and successes.
  • Participate in training, meetings, and professional development activities as required.
  • Travel frequently to healthcare practices to support on-site implementation and coaching.
  • Perform other job-related duties as assigned.

Qualifications

• Licensure:Active Registered Nurse (RN) license in good standing required (multi-state licensure preferred or willingness to obtain).

  Education: Bachelor of Science in Nursing (BSN) preferred; associate degree in nursing with relevant experience considered.

  Experience:

  • Experience working in healthcare settings, preferably within primary care practices.
  • Experience supporting quality improvement initiatives, population health, or value-based care programs.
  • Training or experience in root cause analysis and development of quality improvement plans.
  • Experience leading or supporting initiatives within interdisciplinary clinical teams.

• Skills:

  • Strong communication, coaching, and interpersonal skills to build trust and collaboration with clinical teams.
  • Proficiency in Microsoft Office and electronic medical record (EMR) systems.
  • Knowledge of HEDIS/STAR measures, risk adjustment, and value-based care principles.
  • Ability to analyze data and translate insights into actionable practice improvements.
  • Ability and willingness to travel frequently to practices and community sites.
  • Bilingual candidates strongly preferred.

The working environment and physical requirements of the job include:

In-office work is performed indoors in a traditional office setting with air conditioning, artificial light, and an open workspace. Travel is required between primary care practice locations and office work may be varied due to practice settings.

In this position you will need 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 for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 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.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require a reasonable accommodation during the application or employment process, please indicate this in your application or speak with your recruiter during the hiring process.

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.

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 APPs: 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.