Nurse Quality and Care Gap Coordinator

Job Description

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 2–3 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 compliance—while helping rural patients receive the preventive and chronic care they need.