Value Based Care Advocate

The Value Based Advocate supports the organizations efforts to succeed under value-based contracts by ensuring coordination of care, closing gaps in care, monitoring performance against quality and cost metrics, and helping drive continuous improvement in patient outcomes and operational efficiency.

• →Monitor and analyze patient/population data to identify care gaps (preventive, chronic disease management, transitions of care) and support outreach efforts.
• →Assist care teams (primary care, specialists, case managers, community resources) to coordinate patient care, particularly for high‑risk or complex patients.
• →Support the implementation of care plans, patient education, and follow-up activities, including scheduling, reminders, telephonic outreach and barrier identification.
• →Track and report on key performance indicators (KPIs) such as readmission rates, chronic disease control, preventive screening rates, patient satisfaction, and cost/utilization measures.
• →Work with payer data, internal dashboards and EMR/population-health platforms to extract insights, identify trends, escalate issues, and support improvement initiatives.
• →Engage with patients to support adherence to care plans, resolve social determinants of health issues, and promote overall patient engagement.
• →Collaborate with internal stakeholders to align processes and workflows with value-based care model objectives.
• →Provide documentation, prepare reports, maintain records of outreach/intervention activities, and contribute to process development.
• →Participate in team meetings/huddles and training; stay informed about best practices in value-based care.
• →Other duties as assigned that support the value-based care program.

• Medical doctor with 1-5 years of experience in behavioral health preferred. Healthcare support experience (care coordination, population health, analytics, or value-based care environment preferred).
• Strong analytical ability and comfort working with data.
• Excellent interpersonal and communication skills.
• Bilingual fluency in English and Spanish.
• Organized and able to manage multiple tasks.
• Ability to work independently and escalate appropriately.
•  Proficiency with Microsoft Office and comfort with health IT platforms.
• Patient-centered mindset and awareness of social determinants of health.