Bilingual Clinical Care RN – Transitions & Quality

CenterWell Senior Primary Care; Dallas (TX); On-site; USD 71,000 - 98,000; Full time

Job summary

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) to support patient transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars and quality performance in a clinic-based setting. You will leverage Athena EMR and DataHub to identify gaps and coordinate post-discharge follow-up with providers and patients.

Ideal candidates hold ADN/BSN with an active RN license, bilingual English/Spanish, and 3+ years' nursing experience in transitions of care or

Qualifications

• Must meet one of the following requirements: ADN or BSN.
• Active, unrestricted RN license (state-specific as applicable).
• Bilingual in English and Spanish with full professional proficiency
• 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer's population health tools), and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS measures and Transitions of Care.
• Coordinate timely post-discharge follow-up to address TOC and TC M requirements and prevent readmissions.
• Outreach to patients and providers via phone, telehealth and in-clinic visits to educate on preventive care and chronic disease management.
• Document outreach efforts and clinical interactions per CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement interventions and optimize workflows.

Skills

Clinical nursing

Data analysis

Bilingual English/Spanish

EHR proficiency

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) to support patient transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars and quality performance in a clinic-based setting. You will leverage Athena EMR and DataHub to identify gaps and coordinate post-discharge follow-up with providers and patients.

Ideal candidates hold ADN/BSN with an active RN license, bilingual English/Spanish, and 3+ years' nursing experience in transitions of care or