Case Manager, Value Based

Case Manager, Value Based Location: Remote, with occasional in-office attendance as required Organization: Tampa Family Health Centers Position Type: Full-Time, Non-Exempt About Tampa Family Health Centers At Tampa Family Health Centers, healthcare is more than a service—it’s our mission. As a Federally Qualified Health Center, we provide high-quality, compassionate, and accessible healthcare to a culturally diverse community across Hillsborough County. Joining TFHC means becoming part of a mission-driven organization where every team member plays a vital role in supporting exceptional patient care and improving the healthcare experience for the communities we serve. Position Summary The Value-Based Case Manager plays a critical role in advancing Tampa Family Health Centers’ value-based care strategy by improving clinical outcomes, reducing total cost of care, and supporting quality performance for Accountable Care Organizations (ACO) and managed care plans. This position focuses on proactive patient outreach, care coordination, and performance improvement aligned with HEDIS, STARS, and other quality adherence measures. The Value-Based Case Manager works collaboratively as part of the care team to implement evidence-based protocols for primary care patients. Essential Responsibilities Support strategies to reduce unnecessary healthcare utilization while ensuring high-quality, patient-centered care. Track and analyze utilization patterns, care gaps, and outcomes for assigned patient populations. Identify and prioritize patients who impact quality, utilization, and cost outcomes. Complete chart preparation to facilitate completion of Value-Based Services priorities, including care gaps, referrals, and laboratory ordering. Review electronic and hard-copy medical records and supporting documentation to abstract clinical data for value-based reporting. Document findings in applicable value-based databases and prescribed cloud-based platforms. Attend regular meetings with assigned carriers to review plan data and develop strategies to improve outcomes for patient cohorts. Prepare and present value-based data reports to the Executive Vice President of Value Based Services. Train and advise healthcare professionals and clinical and administrative staff regarding value-based compliance. Establish patient follow-up schedules and monitor patient progress using electronic care management tracking systems within the Electronic Health Record (EHR). Monitor ENS and hospital discharge reports to facilitate patients' connection with appropriate care. Conduct inbound and outbound telephone outreach to patients identified as having high-risk, chronic, and complex care needs. Meet with patients and/or supportive family members or responsible parties to assess current needs and barriers and establish patient-directed, measurable goals. Utilize educational materials, brief intervention techniques, and community resources to engage…