Position Summary

The Value-Based Care (VBC) Quality & Coding Nurse is responsible for closing quality gaps across the organization's patient population participating in MSSP, LEAD, and other risk-based arrangements. This role combines clinical judgment, provider engagement, and data analysis to identify open quality measures and coding opportunities, and to drive timely closure through direct provider outreach and workflow coordination. The ideal candidate is comfortable working in large claims and clinical datasets, translating data into action, and holding providers accountable to close-the-gap timelines that directly affect quality scores, benchmark performance, and shared savings/loss outcomes.

Key Responsibilities

Quality Gap Closure

• Identify open quality gaps (e.g., HEDIS-aligned ACO quality measures, MIPS measures, Annual Wellness Visit completion, screening and preventive care measures) across beneficiaries using ACO/EHR/claims data.
• Prioritize outreach based on gap type, time remaining in the performance year, and impact on overall quality score.
• Direct and coordinate with providers and care teams to close gaps - scheduling outreach, flagging patients due for services, and following up until gaps are documented as closed.
• Track gap closure progress against internal targets and CMS reporting deadlines; escalate stalled cases to practice leadership.

Provider Direction & Engagement

• Serve as the point of contact between the ACO/VBC program and participating providers/practices on quality performance.
• Provide point-of-care coaching on documentation requirements needed to satisfy quality measure specifications.
• Support providers in building repeatable workflows (pre-visit planning, standing orders, registries) so gap closure becomes part of routine care rather than one-off outreach.

Data Management & Analysis

• Manage and interpret large datasets from CCLF/claims feeds, EHR extracts, and quality reporting platforms to identify trends, outliers, and at-risk populations.
• Maintain gap lists, dashboards, and tracking tools; validate data accuracy against source systems.
• Partner with analytics/IT to troubleshoot data discrepancies (e.g., attribution mismatches, missing encounters, lag in claims).

Risk Adjustment & Coding Opportunity Identification

• Review clinical documentation and claims history to identify suspected but unreported HCC/risk-adjustment coding opportunities and recapture needs.
• Flag chronic conditions requiring annual recapture and communicate findings to providers ahead of or during visits.
• Support coding accuracy education for providers (specificity, documentation linkage, recapture cadence) in partnership with coding/compliance staff.
• Monitor RAF trends and coding capture rates at the practice and provider level.

Compliance & Reporting

• Ensure all outreach and documentation activities comply with CMS MSSP/ACO REACH/LEAD program requirements and applicable privacy regulations (HIPAA).
• Support preparation of quality data for CMS submission windows and internal audit readiness.
• Maintain accurate records of all gap-closure and coding-opportunity activity for audit and performancereporting purposes.

Required Qualifications

• Active nursing license.
• 2+ years of experience in long term care, value-based care, quality improvement, or care management.
• Demonstrated ability to work with large datasets (claims, EHR extracts, registries) in Excel or reporting/BI tools.
• Strong provider-facing communication skills; comfortable directing and holding providers accountable to timelines.
• Excellent organizational skills and ability to manage multiple concurrent gap-closure workstreams.

Preferred Qualifications

• Experience with CCLF data, ACO quality reporting tools, or risk-adjustment/coding software.
• Certified Risk Adjustment Coder (CRC) or similar coding credential.
• Familiarity with EHR systems commonly used across a multi-practice network.
• Prior experience in an ACO, health system population health department, or MSO.

Key Performance Indicators

• Quality gap closure rate (overall and by measure) relative to targets and CMS deadlines.
• Improvement in HCC recapture/coding capture rate year over year.
• Provider engagement/response rate.

Must have the ability to pass a background check.