Bilingual Clinical Care RN — Transitions & Quality

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

Job summary

CenterWell is seeking a Clinical Care RN (In-center) to support Transitions of Care and improve Medicare Advantage Stars performance in a Dallas-area clinic. The role emphasizes patient education, outreach, and data-driven quality improvement, with a clinic-based schedule and collaboration across care teams.

The RN will analyze data from Athena EMR/DataHub, coordinate post-discharge follow-ups, and engage patients to prevent readmissions while aligning with CMS standards and center values.

Qualifications

• Must have ADN or BSN in nursing.
• Active, unrestricted RN license.
• Bilingual in English and Spanish.
• 3+ years’ clinical nursing with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with EHR and data analytics tools (Athena EMR, DataHub, Compass Rose, Salesforce HealthCloud, MS Office).
• 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/HEDIS and TOC/TCM.
• Identify recently discharged patients and coordinate timely post-discharge follow-up.
• Outreach to patients and providers via phone, telehealth, and in-clinic visits to close care opportunities.
• Educate patients on preventive care, chronic disease management, and medication management.
• Document all outreach and outcomes per CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Participate in quality improvement projects and staff education.
• Support clinic operations and community education initiatives.

Skills

Bilingual in English and Spanish

Clinical nursing experience

Data analysis

Communication skills

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell is seeking a Clinical Care RN (In-center) to support Transitions of Care and improve Medicare Advantage Stars performance in a Dallas-area clinic. The role emphasizes patient education, outreach, and data-driven quality improvement, with a clinic-based schedule and collaboration across care teams.

The RN will analyze data from Athena EMR/DataHub, coordinate post-discharge follow-ups, and engage patients to prevent readmissions while aligning with CMS standards and center values.