Care Continuity RN: Transitions & Quality Medicare Stars

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

Benefits offered by this job

Medical, dental, and vision benefits

401(k) retirement savings plan

Time off including holidays

Disability and life insurance

Job summary

CenterWell Senior Primary Care in Florida seeks a Clinical Care RN to support safe transitions of care and reduce avoidable ED visits. You will analyze data, coordinate post-discharge follow-ups, and engage patients and providers to drive evidence-based interventions that improve Star ratings and quality metrics.

The role requires an active RN license (ADN/BSN), 3+ years in clinical nursing, bilingual English/Spanish, and proficiency with Athena EMR, DataHub, and MS Office.

Qualifications

• Active, unrestricted RN license (state-specific as applicable).
• Associate's or Bachelor's degree in nursing (ADN/BSN).
• 3+ years of clinical nursing with exposure to transitions of care or population health.
• Bilingual in English and Spanish with full professional proficiency.
• Proficiency with Athena EMR, DataHub, Compass Rose, Salesforce HealthCloud, and Microsoft Office.

Responsibilities

• Analyze clinical data trends from Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS.
• Coordinate timely post-discharge follow-up for discharged patients in alignment with TOC/TCM.
• Conduct outreach via phone, telehealth and in-clinic visits to educate and support patients.
• Document outreach and clinical interactions accurately per CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions.
• Participate in center huddles, quality improvement initiatives, and provider education.
• Support clinic operations and patient engagement to improve health outcomes.

Skills

Bilingual EN/ES

RN licensure

Data analytics

EHR systems

Microsoft Office

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office Suite

Job description

CenterWell Senior Primary Care in Florida seeks a Clinical Care RN to support safe transitions of care and reduce avoidable ED visits. You will analyze data, coordinate post-discharge follow-ups, and engage patients and providers to drive evidence-based interventions that improve Star ratings and quality metrics.

The role requires an active RN license (ADN/BSN), 3+ years in clinical nursing, bilingual English/Spanish, and proficiency with Athena EMR, DataHub, and MS Office.