Care Coordination and Value-Based Care Director

Care Coordination And Value-Based Care Director

Tapestry 360 Health is a mission-driven, patient-centered Federally Qualified Health Center (FQHC) delivering comprehensive primary care, behavioral health, and enabling services to a diverse and underserved population. As a Health Resources and Services Administration-designated health center operating under Section 330 of the Public Health Service Act, Tapestry serves as a critical safety-net provider, ensuring access to high-quality, equitable care regardless of a patient's ability to pay.

With a workforce of approximately 250 employees and an annual operating budget of $44 million, the organization is advancing a deliberate strategy focused on financial sustainability, operational rigor, and long-term community impact. Key priorities include strengthening core infrastructure, expanding value-based care arrangements to align reimbursement with outcomes, and optimizing participation in the 340B Drug Pricing Program to reinvest resources into patient care.

Through this integrated approach, Tapestry 360 Health is positioned to sustain and scale mission-critical services for the communities it serves well into the future.

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,…