Practice Facilitator

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.

The Practice Facilitator is a healthcare professional essential for guiding, coaching, and supporting Value-Based Payment Programs within medical practices. This role manages relationships with practice leadership and drives transformation in quality improvement and patient-centered care models. The Practice Facilitator focuses on improving clinical outcomes, streamlining operational workflows, and enhancing the total cost of care for populations by promoting best practices and integrating supportive care delivery models.

Frequent travel to healthcare practices and community sites is required to ensure direct collaboration and on-site implementation support.

• Facilitate understanding of value-based payment programs, such as ACOs, HEDIS, and Risk Scores.
• Present payor performance scorecards to review benchmarks and develop improvement strategies.
• Develop and provide quality improvement plans with tailored data, tools, and resources to support value-based care models.
• Obtain EMR access and provide support to close gaps in care and identify high-risk patients.
• Review high risk patients with providers, engage in high risk case management as needed, complete transitions of care as needed, and close quality gaps.

• Facilitate performance-based interventions with internal SMEs for HEDIS/STAR and risk adjustment benchmarks.
• Analyze practice-specific scorecards to identify trends and gaps and recommend improvements.
• Deliver education on ICD-10/CPT coding accuracy, risk adjustment, and population health management (e.g., TOC, AWVs, Diagnostic Attestation).
• Guide action plans using models like Plan-Do-Study-Act (PDSA) to drive care transformation and workflow efficiency.
• Monitor key performance indicators (KPIs) and medical loss ratio (MLR) to drive improvements in quality measures and total cost of care (TCOT).

• Build trust-based relationships with practices and care teams.
• Collaborate cross-functionally with internal departments and external stakeholders (e.g., IPAs, Providers, Payors).
• Act as a liaison between Care at Home and healthcare practices to ensure coordinated efforts.

• Act as an SME, supporting activities such as Transitions of Care (TOC), Pre-visit Planning, and Annual Wellness Visits (AWVs).
• Update and maintain internal and practice facing health data portals for quality tracking and reporting.
• Identify drivers of medical expenses and recommend remediation strategies.

• Develop and maintain detailed project plans, tracking milestones, deadlines, and outcomes to ensure successful implementation of practice transformation strategies.
• Coordinate multiple projects simultaneously, managing priorities and resources effectively to meet the needs of diverse practices and stakeholders.
• Conduct scorecard analyses and develop action plans to enhance KPIs, including Quality, Risk Adjustment, Utilization, and practice growth metrics.
• Conduct regular check-ins with practices to ensure alignment with value-based care goals and identify emerging needs.
• Coordinate logistics for practice engagement meetings, including scheduling, agenda creation, and follow-up communications.
• Maintain up-to-date knowledge of healthcare regulations and value-based care models to provide relevant guidance to practices.
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