Quality Care Coordinator

NeighborHealth Center•Raleigh, NC

7d•Onsite

About The Position

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. The role supports quality improvement initiatives by helping ensure patients receive recommended screenings, assessments, follow-up appointments, and other evidence-based healthcare services. The coordinator contacts patients through approved channels, addresses barriers to care, facilitates appointment scheduling, and documents completed interventions. The position is on-site and full-time. The coordinator works with patient registries, electronic health records, quality dashboards, reports, care management platforms, and reporting tools. Work includes monitoring quality measures and care gap closure, supporting audits and reporting, coordinating with clinical and administrative teams, and maintaining accurate documentation in accordance with organizational policies, HIPAA, and privacy and security requirements. This is a nonexempt position. Duties may change over time to meet the needs of the team and patients served.

Requirements

High school diploma or equivalent required.
At least two years of experience in a healthcare setting; primary care, population health, care coordination, or quality improvement experience is preferred, and FQHC or community health experience is strongly preferred.
Computer literacy, including internet use and a Windows environment with 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 follow-through.
Strong organizational skills and 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 coworkers and community members.
Ability to serve as an advocate for individuals of all ethnicities, genders, ages, and backgrounds.
Working knowledge of medical terminology.
Familiarity with preventive care and chronic disease management guidelines, including 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.
Ability to work on-site Monday through Friday during the hours of 7:45 a.m. and 5 p.m.
Ability to read, write, speak, and comprehend English fluently as needed for essential job functions, including patient communication, documentation, and safety-related instructions.
Ability, with or without reasonable accommodation, to sit or stand often for prolonged periods and carry or lift objects up to 20 pounds.
Up-to-date immunizations as required for the role, subject to medical or religious exemption requests in accordance with applicable law and NHC policy.

Nice To Haves

Bilingual in English and Spanish.
Associate degree in a health-related field.
Certification as a Medical Assistant (CMA, RMA, or CCMA), Community Health Worker, or similar credential.
Experience with Epic EHR and population health or registry tools.
FQHC or community health experience.

Responsibilities

Review patient registries, electronic health records, quality dashboards, and reports to identify outstanding preventive care and chronic disease management gaps.
Identify patients 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, ACOs, value-based care initiatives, and internal quality improvement programs.
Maintain accurate tracking lists showing 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 identified care gaps from initial outreach through service completion and documentation.
Conduct proactive patient outreach by telephone, text message, patient portal, mailed correspondence, and other approved communication channels.
Explain 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 appropriate licensed clinical staff.
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 to improve preventive service completion, reduce missed appointments, and enhance continuity of care.
Maintain accurate documentation to support audit readiness and compliance with organizational policies and quality program requirements.
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 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.
Document outreach activities, care gap status, patient communications, and follow-up actions accurately, timely, and completely.
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 HIPAA and organizational privacy and security policies.