Nurse Quality and Care Gap Coordinator

Job Id:  187 # of Openings:  1

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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.

 

• 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 

• 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) 

• 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 

• 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 

• 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 

• 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 

• 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 

• 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 

• 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