Bilingual RN - Transitional Care & Data-Driven Outcomes

Jobtailor

Peoria (AZ)

On-site

USD 85,000 - 110,000

Full time

13 days ago

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Job summary

Jobtailor is seeking a registered nurse in Arizona to improve patient outcomes through quality care and effective transitions of care. You will coordinate post-discharge follow-up, prevent readmissions, and analyze data in Athena EMR and DataHub to close care gaps.

The role requires 3+ years of nursing experience, an active AZ license, bilingual English/Spanish, and proficiency with EMR/Data analytics tools. Expect a 5-day workweek at clinics with potential time beyond standard hours.

Qualifications

Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN).
Active, unrestricted RN license in the State of Arizona.
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 such as Athena EMR.
Proficiency with data analytics tools such as DataHub, Compass Rose, and Salesforce HealthCloud.
Proficiency with Microsoft Office Suite.
Must reside in the designated market area within reasonable commuting distance to assigned clinics.
Valid state driver's license.
Personal vehicle liability insurance meeting specified minimum limits.
Ability to work Monday–Friday, 8:00 AM–5:00 PM, with additional time as required.

Responsibilities

Improve patient outcomes through clinical quality and transitions-of-care support.
Coordinate follow-up for recently discharged inpatient, observation, and emergency department patients.
Prevent avoidable readmissions and emergency department return visits.
Analyze clinical data and trends in Athena EMR and DataHub to identify Stars, HEDIS, and transition-of-care gaps.
Conduct patient and provider outreach by phone, telehealth, and in-clinic visits.
Provide education on preventive care, chronic disease management, medication management, and self-management.
Perform post-discharge assessment, medication reconciliation, symptom monitoring, and follow-up adherence checks.
Identify and elevate barriers in collaboration with providers and care teams.
Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
Document outreach, clinical interactions, patient encounters, and outcomes in compliance with organizational and CMS standards.
Participate in center huddles and high-risk rounds.
Participate in quality improvement projects, provider education sessions, and team huddles.
Monitor Stars and Transitional Care Management goals and develop solutions to improve performance and engagement.
Support clinic operations, care coordination, community education, and market-based wellness events.
Maintain patient confidentiality in accordance with HIPAA.
Follow safety, infection control, attendance, and organizational policies.
Perform other duties as assigned.