Bilingual RN: Transitions & Quality Improvement

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

Job summary

CenterWell Senior Primary Care in Dallas is seeking a Clinical Care Nurse (RN) to support safe transitions of care and improve Medicare Advantage Stars and HEDIS performance. The role emphasizes patient education, outreach, and data-driven quality improvement across inpatient, observation, and ED discharges.

The RN will collaborate with providers and care teams to close care opportunities, manage chronic disease education, and ensure adherence to discharge plans while maintaining HIPAA

Qualifications

• Registered nurse with active, unrestricted license (state-specific).
• ADN or BSN required or equivalent.
• 3+ years clinical nursing with exposure to transitions of care or population health.
• Proficient with electronic health records (Athena EMR) and data analytics tools.
• Fluent in English and Spanish with professional proficiency.

Responsibilities

• Analyze clinical data to identify gaps in care related to TOC, Stars, and HEDIS measures.
• Coordinate post-discharge follow-up for discharged inpatients, observation, and ED patients.
• Outreach to patients and providers via phone, telehealth, and in-clinic visits to close care opportunities.
• Conduct discharge instruction reviews, medication reconciliation, and adherence checks.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and improve workflows.
• Document outreach and clinical interactions in the medical record per CMS standards.
• Participate in center huddles, high-risk rounds, and quality improvement activities.
• Monitor progress toward Stars and TCM goals and identify barriers to improvement.

Skills

RN license (state)

Bilingual English/Spanish

3+ years clinical nursing

Athena EMR experience

Data analytics tools

MS Office

Basic Life Support

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office Suite

Job description

CenterWell Senior Primary Care in Dallas is seeking a Clinical Care Nurse (RN) to support safe transitions of care and improve Medicare Advantage Stars and HEDIS performance. The role emphasizes patient education, outreach, and data-driven quality improvement across inpatient, observation, and ED discharges.

The RN will collaborate with providers and care teams to close care opportunities, manage chronic disease education, and ensure adherence to discharge plans while maintaining HIPAA