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