Quality Care Coordinator

This position is an on-site role.

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. This role supports quality improvement (QI) initiatives by ensuring patients receive recommended screenings, assessments, follow-up appointments, and other evidence-based healthcare services. Through telephone calls, text messages, patient portal communications, and other approved outreach methods, the quality care coordinator engages patients, addresses barriers to care, facilitates appointment scheduling, and documents completed interventions.

Care Gap Identification and Tracking

• Review patient registries, electronic health records, quality dashboards, and reports to identify outstanding preventive care and chronic disease management gaps.
• Identify patients who are 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, accountable care organizations (ACOs), value-based care initiatives, and internal quality improvement programs, as relevant to the organization.
• Maintain accurate and up-to-date tracking lists of patients with open care gaps, including 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 the status of identified care gaps from initial outreach through service completion and documentation

Patient Outreach and Engagement

• Conduct proactive outreach to patients with identified care gaps using approved communication channels, including telephone calls, text messages, patient portals, and mailed correspondence.
• Explain the purpose and importance of 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 the appropriate licensed clinical staff.

Quality Metrics and Performance Monitoring

• 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 designed to improve preventive service completion, reduce missed appointments, and enhance continuity of care.
• Maintain accurate documentation to support audit readiness and compliance with applicable organizational policies and quality program requirements.

Collaboration and Care Coordination

• 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 the 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.

Documentation, Compliance, and Confidentiality

• Maintain accurate, timely, and complete documentation of outreach activities, care gap status, patient communication, and follow-up actions.
• 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 applicable HIPAA requirements and organizational privacy and security policies.

This description covers the primary responsibilities of the role, but it isn't meant to capture everything. Duties may change over time to meet the needs of the team and the patients we serve.