Quality Care Coordinator

This position is an on-site role.

The Quality Care Coordinator is responsible for identifying, tracking, and closing preventive care and chronic disease management gaps through proactive patient outreach, care coordination, and collaboration with clinical teams. This role supports quality improvement (QI) initiatives by ensuring patients receive recommended screenings, assessments, follow-up appointments, and other evidence-based healthcare services. Through telephone calls, text messages, patient portal communications, and other approved outreach methods, the quality care coordinator engages patients, addresses barriers to care, facilitates appointment scheduling, and documents completed interventions.

Care Gap Identification and Tracking

• Review patient registries, electronic health records, quality dashboards, and reports to identify outstanding preventive care and chronic disease management gaps.
• Identify patients who are overdue for recommended screenings, immunizations, wellness visits, laboratory tests, follow-up appointments, and other quality-related services.
• Monitor care gaps associated with applicable quality programs, including HEDIS, Medicare Stars, accountable care organizations (ACOs), value-based care initiatives, and internal quality improvement programs, as relevant to the organization.
• Maintain accurate and up-to-date tracking lists of patients with open care gaps, including outreach status, scheduled appointments, completed services, and unresolved needs.
• Prioritize outreach based on clinical urgency, measure deadlines, patient risk, and organizational quality improvement goals.
• Validate care gap information against available medical records and communicate discrepancies to appropriate clinical or quality team members.
• Monitor the status of identified care gaps from initial outreach through service completion and documentation

Patient Outreach and Engagement

• Conduct proactive outreach to patients with identified care gaps using approved communication channels, including telephone calls, text messages, patient portals, and mailed correspondence.
• Explain the purpose and importance of recommended preventive services in clear, patient-friendly language.
• Encourage and assist patients with appointment scheduling, rescheduling, referral coordination, and preparation for recommended services.
• Escalate clinical questions, urgent concerns, and complex care coordination needs to the appropriate licensed clinical staff.

Quality Metrics and Performance Monitoring

• Monitor care gap closure rates, outreach completion rates, patient contact rates, appointment scheduling outcomes, and other assigned quality indicators.
• Generate routine reports and PDSA documentation to track tests of change.
• Review open care gaps and identify patients requiring additional outreach or escalation.
• Assist with chart reviews, data validation, quality audits, and preparation for internal or external quality reporting.
• Identify trends in missed care opportunities and recommend workflow improvements to increase patient participation and measure performance.
• Support quality improvement projects designed to improve preventive service completion, reduce missed appointments, and enhance continuity of care.
• Maintain accurate documentation to support audit readiness and compliance with applicable organizational policies and quality program requirements.

Collaboration and Care Coordination

• Partner with providers, nurses, medical assistants, care managers, population health teams, and quality improvement staff to coordinate care gap closure activities.
• Participate in quality meetings, team huddles, case reviews, and performance improvement discussions.
• Collaborate with scheduling teams and referral coordinators to facilitate timely access to recommended services.
• Support the development and implementation of standardized outreach scripts, tracking tools, escalation procedures, and care gap workflows.
• Coordinate with CHW when social or logistical barriers prevent patients from completing recommended care.

Documentation, Compliance, and Confidentiality

• Maintain accurate, timely, and complete documentation of outreach activities, care gap status, patient communication, and follow-up actions.
• Use approved electronic health record systems, care management platforms, registries, and reporting tools.
• Follow organizational policies for patient identification, communication preferences, consent, and documentation.
• Protect confidential patient information and comply with applicable HIPAA requirements and organizational privacy and security policies.

This description covers the primary responsibilities of the role, but it isn't meant to capture everything. Duties may change over time to meet the needs of the team and the patients we serve.

Requirements

• Bilingual in English and Spanish preferred
• Computer literacy in internet use and Windows environment, including Outlook, Word, and Excel.
• Proficiency with electronic health records, registries, and quality reports
• Ability to explain preventive care to patients in clear, plain language and encourage them to follow through
• Strong organizational skills, with the ability to manage large patient lists and prioritize outreach
• High attention to detail and accuracy in documentation
• Ability to recognize when a patient needs a licensed clinician and escalate promptly
• Ability to cultivate and develop inclusive and equitable working relationships with co-workers and community members
• Ability to serve as an advocate for individuals of all ethnicities, genders, ages, and backgrounds

Required Knowledge, Experience, or Licensure/Registration

• High school diploma or equivalent required; associate degree in a health-related field preferred
• Ability to work onsite Mondays through Fridays during the hours of 7:45 am and 5 pm.
• Certification as a Medical Assistant (CMA, RMA, or CCMA), Community Health Worker, or similar credential preferred
• At least two years of experience in a healthcare setting, preferably in primary care, population health, care coordination, or quality improvement; FQHC or community health experience strongly preferred
• Working knowledge of medical terminology
• Familiarity with preventive care and chronic disease management guidelines, such as cancer screenings, immunizations, diabetes and hypertension monitoring, and well visits
• Understanding of quality measures and reporting programs such as UDS, HEDIS, Medicare Stars, PCMH, and value-based care models
• Basic understanding of quality improvement methods, including PDSA cycles
• Knowledge of HIPAA and patient privacy requirements
• Experience with Epic EHR system and with population health or registry tools preferred
• If approved to work remotely, the ability to work in a private home workspace — where screens and conversations cannot be seen or overheard by others — with a secure, password-protected home internet connection (not shared or public Wi-Fi), sufficient to protect patient confidentiality at all times.
• Ability to read, write, speak, and comprehend English fluently as needed to perform essential job functions, including patient communication, documentation, and safety-related instructions.

Physical requirements of the Job

With or without reasonable accommodation, this position requires the ability to:

• Sit or stand, often for prolonged periods
• Carry or lift objects up to 20 pounds

Health and Safety Requirements

Up-to-date immunizations as required for the role, subject to medical or religious exemption requests in accordance with applicable law and NHC policy.

This is a full-time, nonexempt position.

NeighborHealth Center is an Equal Opportunity Employer, dedicated to serving a diverse patient population and building a staff reflective of the communities we serve. We encourage applications from women, minority groups, veterans, and people with disabilities.