Nurse Quality and Care Gap Coordinator

Nurse Quality And Care Gap Coordinator

The Nurse Quality and Care Gap Coordinator is a registered nurse responsible for improving patient outcomes by identifying, tracking, and closing preventive and chronic care gaps in a Rural Health Clinic (RHC) setting. This role supports value-based care initiatives, payer quality programs, and regulatory requirements while working collaboratively with providers, staff, and patients to ensure evidence-based, timely, and patient-centered care. This position plays a critical role in population health management, quality reporting, and care coordination especially for underserved or rural populations.

Key Responsibilities:

• Quality & Care Gap Management
• Identify care gaps using EHR reports, payer portals (HEDIS, STAR, CMS, Medicaid MCOs), and internal dashboards
• Prioritize high-risk and high-impact patient populations (diabetes, hypertension, CHF, COPD, preventive care)
• Coordinate closure of gaps such as: Annual Wellness Visits (AWV) Texas Health Steps / Well-child visits Diabetes (A1c, nephropathy, retinal exams) Immunizations Cancer screenings (breast, cervical, colorectal) Depression screening and follow-up
• Care Coordination & Patient Outreach
• Conduct patient outreach via phone, portal, or mail to schedule needed services
• Educate patients on the importance of preventive care and chronic disease management
• Coordinate referrals, follow-ups, and outside records to support gap closure
• Serve as a patient advocate to reduce barriers to care (transportation, access, understanding)
• Clinical Quality & Documentation Support
• Ensure accurate, compliant clinical documentation to support quality measures
• Collaborate with providers to close gaps during visits ("visit-based gap closure")
• Assist with development and use of EHR tools such as templates, smart phrases, and reminders
• Support compliance with CMS, Medicaid, and commercial payer quality requirements
• Data Tracking & Reporting
• Track quality performance metrics and trends
• Prepare reports for leadership, payers, and governing boards
• Monitor audit readiness and assist with payer or regulatory audits
• Identify opportunities for quality improvement and workflow optimization
• Staff Education & Collaboration
• Educate clinical and front-desk staff on quality initiatives and care gap workflows
• Promote a culture of quality, accountability, and continuous improvement
• Serve as a clinical resource for evidence-based guidelines and preventive care standards

Job Qualifications:

• Active, unrestricted Registered Nurse (RN) license (state of practice)
• Minimum 23 years of clinical nursing experience
• Experience in primary care, rural health, family practice, or population health
• Strong understanding of preventive care guidelines and chronic disease management
• Proficiency with EHR systems and basic data reporting

Preferred Qualifications:

• Experience in a Rural Health Clinic (RHC) or FQHC
• Familiarity with: HEDIS, STAR, MIPS, or Medicaid quality programs Texas Health Steps (if applicable)
• Value-based care models
• Previous quality improvement, care coordination, or case management experience
• BSN preferred

Key Skills & Competencies:

• Strong organizational and follow-up skills
• Excellent communication and patient education abilities
• Ability to work independently and manage multiple priorities
• Analytical thinking with attention to detail
• Collaborative, solutions-oriented mindset

Work Environment:

• Primarily clinic-based with administrative and clinical responsibilities
• May include phone-based patient outreach and care coordination
• Requires close collaboration with providers, nursing staff, and leadership

Impact of the Role:

This position directly improves patient outcomes, clinic quality scores, reimbursement performance, and regulatory compliancewhile helping rural patients receive the preventive and chronic care they need.