Practice Facilitator; RN

Overview

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.

Key responsibilities include 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.

• 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 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…