Quality Care Coordinator

NeighborHealth Center•Raleigh, NC

6d•Onsite

About The Position

The Quality Care Coordinator is an on-site role 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. Outreach may be conducted by telephone, text message, patient portal, or other approved methods to engage patients, address barriers to care, facilitate scheduling, and document interventions. The coordinator reviews patient registries, electronic health records, quality dashboards, and reports to identify outstanding care gaps; maintains tracking lists; prioritizes outreach; validates information; and monitors gaps through service completion and documentation. The role also monitors quality metrics, prepares routine reports and PDSA documentation, assists with chart reviews and audits, identifies trends, and supports workflow and quality improvement projects. Working with providers, nurses, medical assistants, care managers, population health and quality improvement teams, scheduling staff, referral coordinators, and community health workers, the coordinator helps coordinate timely care and address social or logistical barriers. The position requires accurate documentation, appropriate escalation of clinical concerns to licensed staff, and compliance with patient communication, confidentiality, HIPAA, and organizational privacy and security requirements. Duties may change to meet the needs of the team and patients.

Requirements

High school diploma or equivalent required.
At least two years of experience in a healthcare setting.
Ability to work onsite Monday through Friday during the hours of 7:45 a.m. and 5 p.m.
Computer literacy, including internet use and the Windows environment, Outlook, Word, and Excel.
Proficiency with electronic health records, registries, and quality reports.
Ability to explain preventive care in clear, plain language and encourage patients to 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 promptly escalate.
Ability to cultivate inclusive and equitable working relationships with coworkers and community members and 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 read, write, speak, and comprehend English fluently as needed for essential job functions, patient communication, documentation, and safety-related instructions.
Up-to-date immunizations as required for the role, subject to medical or religious exemption requests under applicable law and NHC policy.
With or without reasonable accommodation, ability to sit or stand, often for prolonged periods, and carry or lift objects up to 20 pounds.

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 in primary care, population health, care coordination, or quality improvement; FQHC or community health experience is strongly preferred.
Experience with the Epic EHR system and population health or registry tools.
If approved to work remotely, ability to work in a private home workspace with a secure, password-protected home internet connection that protects patient confidentiality.

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 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 current tracking lists showing outreach status, scheduled appointments, completed services, and unresolved needs.
Prioritize outreach based on clinical urgency, measure deadlines, patient risk, and quality improvement goals.
Validate care gap information against available medical records and communicate discrepancies to appropriate clinical or quality team members.
Track identified care gaps from initial outreach through service completion and documentation.
Contact patients through approved methods, explain recommended preventive services in patient-friendly language, and assist with scheduling, rescheduling, referrals, and service preparation.
Escalate clinical questions, urgent concerns, and complex care coordination needs to appropriate licensed clinical staff.
Monitor care gap closure, outreach completion, patient contact, appointment scheduling, and other assigned quality indicators.
Generate routine reports and PDSA documentation, review open gaps, and identify patients requiring further 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.
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.
Collaborate with clinical, population health, quality, scheduling, referral, and community health staff to coordinate care gap closure.
Participate in quality meetings, team huddles, case reviews, and performance improvement discussions.
Support standardized outreach scripts, tracking tools, escalation procedures, and care gap workflows.
Coordinate with community health workers when social or logistical barriers prevent patients from completing recommended care.
Follow policies for patient identification, communication preferences, consent, and documentation; protect patient information and comply with HIPAA and organizational privacy and security policies.