Care Coordination and Value-Based Care Director

Summary: The Director, Care Coordination and Value-Based Care provides strategic and operational leadership for care coordination, population health, and value-based care initiatives across the organization. This role is responsible for advancing an integrated, outcomes-driven care model that improves quality performance, patient experience, care continuity, and health equity, including for high-risk and medically complex populations. The Director oversees multidisciplinary care coordination and care management functions, standardizes workflows and outreach strategies, and drives initiatives that address both clinical and social determinants of health. In partnership with internal leadership, providers, and external organizations, including the MHN ACO, the position supports organizational performance, value-based reimbursement initiatives, and long-term population health outcomes.

Essential Duties and Responsibilities:

• Provides leadership, supervision, and development for multidisciplinary teams, including Care Management, Care Coordination, Cancer Prevention, and Value-Based Care staff.
• Leads and standardizes outreach, care coordination, and population health strategies aligned with organizational quality, health equity, and value-based care initiatives.
• Partners with clinical, quality, operational, and external healthcare partners to support care continuity, improve access to care coordination services, and strengthen interdisciplinary collaboration.
• Oversees care coordination workflows and care management strategies for high-risk, high-utilizing, and medically complex patient populations, including risk stratification, panel management, and performance monitoring
• Leads integration of social determinants of health (SDOH) initiatives into care coordination workflows, referral management processes, and care documentation practices
• Ensures care teams have standardized tools, protocols, training, and community resource connections necessary to address patient care and social support needs effectively.
• Supports organization-wide cancer prevention and screening initiatives, including workflows that promote timely follow-up, patient outreach, and care coordination for abnormal results.
• Drives continuous improvement efforts focused on workflow optimization, operational efficiency, patient outcomes, and advancement of a value-based, outcomes-focused care model.
• Fosters a culture of accountability, collaboration, equity, and continuous improvement across teams and organizational initiatives.
• Ensures compliance with HRSA, UDS, value-based care, and other applicable FQHC regulatory and reporting requirements.

• Identifies opportunities to improve staffing models, resource allocation, workflows, and operational processes to support organizational growth and patient care needs.
• Performs other duties as assigned in support of departmental and organizational objectives.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required Qualifications:

• Bachelor’s degree required in Nursing, Social Work, Public Health, Healthcare Administration, Human Services, or a related healthcare field. An equivalent combination of education, training, and relevant experience may be considered instead of the stated degree requirement.
• Minimum of five (5) years of progressive experience in care coordination, care management, population health, value-based care, or related healthcare operations.
• Minimum of three (3) years of leadership or supervisory experience managing multidisciplinary teams in a healthcare, FQHC, hospital, managed care, or community health setting.
• Strong understanding of value-based care models, population health strategies, care coordination workflows, and quality improvement initiatives.
• Experience working with high-risk, medically complex, and underserved patient populations, including addressing social determinants of health (SDOH) and health equity initiatives.
• Experience developing, implementing, and optimizing workflows, outreach strategies, and care management programs across interdisciplinary teams.
• Demonstrated ability to analyze performance data, monitor quality metrics, and drive operational and clinical improvements.
• Strong leadership, communication, organizational, relationship management, and change management skills.
• Proficiency with electronic medical record (EMR) systems, reporting tools, and population health platforms.

Preferred Qualifications:

• Master’s degree in Public Health, Healthcare Administration, Social Work, Nursing, or a related field preferred.
• Licensed clinical background (e.g., RN, LCSW)preferred.

• Experience working in a Federally Qualified Health Center (FQHC), ACO, managed care, or value-based care environment preferred.
• Familiarity with HRSA, UDS, HEDIS, CMS, and other regulatory and quality reporting requirements preferred.
• Experience collaborating with hospitals, ACOs, managed care organizations, community-based organizations, and external healthcare partners preferred.
• Experience leading population health, cancer prevention, care management, or health equity initiatives preferred.

Competencies: 

• Strategic Leadership & Operational Oversight – Provides leadership and direction for care coordination, care management, and value-based care initiatives to support organizational goals, patient outcomes, and operational performance.
• Population Health & Value-Based Care Expertise – Demonstrates strong knowledge of population health strategies, value-based care models, risk stratification, and care management practices that improve quality outcomes and patient experience.
• Care Coordination & Health Equity – Leads integrated care coordination efforts that address clinical and social determinants of health (SDOH) while promoting equitable access to care and community resources.
• Workflow Optimization & Continuous Improvement – Evaluates and improves workflows, outreach strategies, and operational processes to enhance efficiency, care continuity, and interdisciplinary collaboration.
• Data Analysis & Performance Management – Uses quality metrics, operational data, and performance trends to monitor outcomes, identify opportunities for improvement, and drive data-informed decision-making.
• Regulatory & Compliance Oversight – Ensures compliance with HRSA, UDS, value-based care, and other applicable regulatory and reporting requirements.
• Leadership Development & Team Management – Supervises, coaches, and develops multidisciplinary teams while fostering a culture of accountability, collaboration, equity, and continuous improvement.

Supervisory Responsibilities: Directly supervises leadership and staff within the Care Coordination, Care Management, Cancer Prevention, and Value-Based Care functions.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Work is performed primarily in a healthcare and office environment with regular use of computers, phones, virtual meeting platforms, and standard office equipment.
• The position requires prolonged periods of sitting, standing, walking, speaking, listening, and repetitive hand movements associated with computer and administrative work.
• Must be able to communicate effectively with staff, patients, providers, community partners, and leadership in both onsite and virtual settings.
• The role may require movement between clinical and administrative locations to support care coordination operations, meetings, workflow assessments, staff support, and interdisciplinary collaboration.
• Occasional lifting, carrying, or moving of materials and equipment up to 15 pounds may be required.
• The position may require occasional evening or weekend work to support operational, community, or organizational needs.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Work is performed in a fast-paced healthcare environment requiring frequent collaboration with clinical, operational, administrative, community, and external healthcare partners.
• The role involves balancing multiple priorities, managing interdisciplinary teams, responding to changing patient and operational needs, and supporting time-sensitive organizational initiatives.
• The position requires regular interaction with high-risk, medically complex, and underserved patient populations, including addressing barriers related to social determinants of health and health equity.
• The work environment requires strong leadership, professionalism, adaptability, and the ability to manage complex operational and interpersonal situations while maintaining a patient-centered approach.
• The role may require occasional evening or weekend work to support operational needs, community initiatives, organizational priorities, meetings, or implementation activities.

Benefits: Tapestry 360 Health offers a comprehensive benefits package including health insurance, dental insurance, retirement savings plans, paid time off, continuing education support, and eligibility for the Public Service Loan Forgiveness (PSLF) program. 
 
Pay Transparency: The salary range for this position is $90,000 – $95,000 annually. Actual compensation will be determined based on factors including, but not limited to, relevant experience, qualifications, internal equity, and organizational needs.

EEO Statement  
Tapestry 360 Health is an equal opportunity employer. We make employment decisions without regard to race, color, religion, age, sex, gender identity or expression, sexual orientation, national origin, ancestry, disability, genetic information, veteran or military status, marital or parental status, arrest or conviction record (as permitted by law), receipt of an order of protection, use of protected leave (including FMLA and VESSA), or any other status protected by applicable law.

Americans with Disabilities Act (ADA) Statement 
Tapestry 360 Health complies with the Americans with Disabilities Act (ADA) and provides reasonable accommodations to qualified applicants and employees with disabilities. If you need assistance or an accommodation during the application or hiring process, please contact Human Resources.

Tapestry 360 Health reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract of employment.