Value-Based Care Quality Coordinator (AWV / TCM Outreach) at POTS

Plano, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

21 Sep, 26

Salary

0.0

Posted On

24 Jun, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Patient Outreach, Scheduling, Care Coordination, Population Health, EHR Management, Medicare Compliance, Patient Communication, Workflow Optimization, Performance Reporting, Bilingual Communication

Industry

Hospitals and Health Care

Description

Description ABOUT PRIMOR HEALTH Primor Health dba Rise Health is a multi-state, value-based primary care organization dedicated to delivering proactive, high-quality care to Medicare patients. We focus on prevention, care coordination, and operational excellence to improve outcomes for the communities we serve. As we continue to grow across Texas, New Mexico, and Nevada, we are building the teams, systems, and capabilities needed to scale a high-performing care model. For candidates who want to do meaningful work in a fast-moving environment, Primor offers the opportunity to make a visible impact while growing with the organization. ABOUT THE ROLE The Value-Based Care Quality Coordinator plays an important role in Primor Health’s growth strategy by helping patients access essential preventive and transitional care services. In this position, you will lead outreach and scheduling efforts for Annual Wellness Visits (AWVs) and post-discharge Transitional Care Management (TCM), helping turn care opportunities into completed, compliant visits that support better patient outcomes. This is an excellent opportunity for someone who enjoys combining patient connection, operational follow-through, and measurable impact in a value-based care environment. The role is based in the Dallas–Fort Worth market and offers strong visibility, close partnership with leadership, and the chance to help shape a growing quality program. WHAT YOU WILL DO • Manage daily AWV and TCM / ER worklists generated through internal reporting and the discharge feed, helping ensure each eligible patient receives timely follow-up. • Execute timely patient outreach and scheduling for AWVs and TCM visits, with close adherence to Medicare timing, documentation, and eligibility requirements. • Maintain accurate outreach and contact documentation within the EHR to support team visibility, operational consistency, and reliable performance reporting across Athena and eClinicalWorks. • Help organize outreach workflows and call lists so clinic teams can work more efficiently and prioritize the right patients at the right time. • Support patient identification and compliant outreach for CCM and RPM enrollment, contributing to broader longitudinal care management strategy. • Collaborate with practice managers, front-desk teams, and care navigation partners to improve workflow consistency and support strong execution across DFW sites. • Monitor outreach, scheduling, and completion metrics in partnership with the Director of Quality, helping translate daily activity into measurable progress against AWV, TCM, and growth targets. Requirements • High school diploma or equivalent required • 2+ years in patient outreach, scheduling, care coordination, or population health in a primary-care or clinic setting. • Comfort working in an EHR (Athena and/or eClinicalWorks) and with call or worklist tools, plus a strong phone presence and solid documentation habits. • A working knowledge of Medicare Annual Wellness Visits and Transitional Care Management, or the ability to learn these workflows quickly. • Strong organization, follow-through, and comfort managing a daily worklist in a results-oriented environment. • A professional, patient-centered communication style and a collaborative approach to working with clinic teams. Additional Experience • Bilingual (English / Spanish) — strongly preferred for the communities we serve. • A Medical Assistant (MA / CMA) or Licensed Vocational Nurse (LVN) credential. • Prior experience with AWV / TCM workflows or CCM / RPM enrollment. • Experience working across multiple sites or in a central coordination role. WHAT SUCCESS LOOKS LIKE IN YOUR FIRST 90 DAYS • You establish a dependable operating cadence for AWV and TCM outreach, with timely post-discharge follow-up and clear worklist ownership across assigned clinics. • AWV completion and TCM conversion performance in the DFW market are trending upward, with measurable movement toward quality, access, and revenue targets. • Clinic teams are working from cleaner, better-prioritized outreach lists, and documentation standards are consistent enough to support reliable reporting and scale.

Responsibilities

Lead outreach and scheduling for Annual Wellness Visits and Transitional Care Management to improve patient outcomes. Manage daily worklists and collaborate with clinic teams to ensure compliant, timely follow-up for Medicare patients.