Bilingual Clinical Care RN – Transitions & Stars

CenterWell; Orlando (FL); On-site; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits

Job summary

CenterWell is seeking a Clinical Care Nurse (RN) to support safe transitions of care and drive Medicare Advantage Stars and quality performance. This clinic-based role involves coordinating post-discharge follow-ups, patient education, and collaboration with multi-disciplinary teams to reduce readmissions.

You will analyze data, engage patients and providers, and ensure compliant documentation while supporting health equity and patient-centered care.

Qualifications

• ADN or BSN required.
• Bilingual in English and Spanish with full professional proficiency.
• Active, unrestricted RN license (state-specific as applicable).
• 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 (DataHub, Compass Rose, SalesForce HealthCloud), and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.
• Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and TCM requirements, aiming to address root causes of utilization.
• Conduct targeted outreach via phone, telehealth and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease management, and medication management.
• Conduct post-discharge outreach to assess understanding of discharge instructions and adherence to follow-up.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Document all outreach, clinical interactions, and outcomes in compliance with CMS standards.
• Participate in center huddles and high-risk rounds with providers and teams.

Skills

Bilingual: English & Spanish

EHR proficiency

Data analytics tools

Microsoft Office

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Job description

CenterWell is seeking a Clinical Care Nurse (RN) to support safe transitions of care and drive Medicare Advantage Stars and quality performance. This clinic-based role involves coordinating post-discharge follow-ups, patient education, and collaboration with multi-disciplinary teams to reduce readmissions.

You will analyze data, engage patients and providers, and ensure compliant documentation while supporting health equity and patient-centered care.