Specialist, Care Gap & Chronic Care

POSITION SUMMARY

Care Gap Closure & Pre-Visit Planning is a specialized clinical support position dedicated to improving patient outcomes, preventive care compliance, and clinical visit efficiency through proactive care gap closure and comprehensive pre-visit planning. This position works closely with clinicians, nursing, care management, population health, and practice operations to identify outstanding preventive, chronic disease, and quality-related care needs before the patient’s scheduled visit. The specialist will proactively outreach to patients, coordinate needed services, obtain and reconcile relevant information, prepare the chart, and ensure the care team has the information necessary to address outstanding needs during the encounter. The primary focus of this position is closing care gaps before the patient’s scheduled visit, reducing missed opportunities for care, improving quality performance, and maximizing the effectiveness of every clinical encounter.

REPORTING RELATIONSHIPS

This position reports to the VP, Enterprise Chief Operations Officer. No roles report to this position.

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Care Gap & Chronic Care Specialist will:

Care Gap Identification & Closure

• Review patient registries, quality reports, electronic health record (EHR) alerts, and population health dashboards to identify outstanding care gaps.
• Prioritize care gaps based on clinical importance, patient risk, upcoming appointments, and organizational quality priorities.
• Conduct proactive patient outreach by telephone, patient portal, or other approved communication methods to address outstanding care needs.
• Coordinate completion of appropriate screenings, laboratory testing, immunizations, referrals, and other services necessary to close identified care gaps.
• Obtain outside medical records, test results, and documentation when appropriate to determine whether a care gap has already been addressed.
• Ensure completed services and external records are appropriately documented in the EHR.
• Work with clinical staff to escalate care gaps requiring provider or nursing intervention.
• Track unresolved care gaps and continue outreach until the gap is closed, the patient declines, or the appropriate clinical disposition is documented.
• Support organizational performance on preventive care, chronic disease management, HEDIS, UDS, value-based care, and other applicable quality measures.

Pre-Visit Planning

• Conduct comprehensive pre-visit planning for assigned patients prior to scheduled appointments.
• Review the patient’s chart, health maintenance, preventive care, chronic conditions, recent utilization, laboratory results, referrals, and outstanding care gaps.
• Ensure necessary records, reports, and external documentation are available prior to the patient encounter.
• Contact patients in advance when additional information, testing, records, or preparation is needed.
• Assist the care team in developing an efficient visit plan designed to address as many appropriate care needs as possible during a single encounter.
• Identify opportunities for same-day care gap closure and communicate these opportunities to the clinical team before or during the visit.

Clinical Team Support

• Function as a dedicated resource to providers and clinical teams for care gap identification and pre-visit planning.
• Communicate high-priority or time-sensitive patient needs to the appropriate clinical team member.
• Support providers by ensuring relevant preventive and chronic care needs are visible before the patient enters the exam room.
• Collaborate with nurses, care managers, population health staff, providers, referral coordinators, and practice leadership.
• Participate in daily or weekly huddles to review upcoming patients, outstanding care gaps, and opportunities for intervention.
• Assist in developing and improving workflows designed to increase care gap closure and pre-visit planning effectiveness.
• Identify recurring operational barriers that prevent care gaps from being closed and escalate those barriers to leadership.

Performance Expectations

The Medical Assistant – Care Gap Closure & Pre-Visit Planning Specialist will be accountable for measurable performance related to both activity and outcomes, including:

• Completion of assigned pre-visit planning activities prior to scheduled patient encounters.
• Consistent review of upcoming patient schedules and identification of outstanding care gaps.
• Minimum established weekly care gap outreach activity, based on organizational expectations and patient panel size.
• Demonstrated improvement in care gap closure rates for assigned patient populations.
• Timely and accurate documentation of all outreach and care gap activities.
• Increased percentage of scheduled visits with completed pre-visit planning.
• Increased number of care gaps closed prior to or during the patient encounter.
• Reduction in missed opportunities for preventive and chronic care services.
• Consistent participation in team huddles and population health workflows.
• Achievement of department-specific quality, productivity, and patient engagement targets.

REQUIRED QUALIFICATIONS

• Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• High school diploma or equivalent.
• Basic knowledge of ambulatory clinical workflows and electronic health records.
• Strong organizational and time-management skills.
• Excellent communication and interpersonal skills.
• Ability to work independently while maintaining close collaboration with clinical teams.
• Ability to manage multiple worklists, priorities, and patient outreach activities.
• Demonstrated commitment to patient-centered care and quality improvement.

PREFERRED QUALIFICATIONS

• Experience with population health, care gap closure, value-based care, quality improvement, or pre-visit planning.
• Experience working with HEDIS, UDS, or other quality measures.
• Experience with patient registries and EHR-based outreach tools.
• Experience in an FQHC, primary care, or other value-based care environment.
• High level of professionalism and confidentiality required at all times
• Valid driver’s license with reliable access to an automobile or reliable access to transportation to assigned work areas. 

Notice of AI Use in Job Application Review

As part of our commitment in creating a fair, efficient, and consistent hiring process we may use artificial intelligence (AI) to help our recruiting teams organize, summarize, and analyze information provided by candidates, including resumes, application responses, and other materials submitted during the application process.AI may be used to identify patterns, highlight relevant skills, and experience, and assist in comparing a candidate’s qualifications with the requirement of a specific role. These tools are to improve efficiency and consistency while supporting more informed hiring decisions, which will ultimately be made by the hiring team.