Care Transitions RN — Quality & Stars Advocate

Conviva Senior Primary Care; Palm Coast (FL); On-site; USD 65,000 - 85,000; Full time

Job summary

Conviva Senior Primary Care seeks a Clinical Care Nurse (RN) to support safe transitions of care and improve Medicare Advantage Stars and quality performance. The clinic-based role involves proactive patient outreach, care coordination, and education across TOC and post-discharge processes.

Ideal candidates will analyze data from Athena EMR and other tools, coordinate follow-ups, and collaborate with providers and care teams to prevent readmissions and enhance patient outcomes.

Qualifications

• Requires ADN or BSN in Nursing.
• Active, unrestricted RN license in Florida.
• 3+ years clinical nursing with exposure to transitions of care, quality improvement, or population health.

Responsibilities

• Analyze clinical data and trends in EMR/data platforms to identify gaps in care related to Stars, HEDIS, and Transitions of Care.
• Coordinate timely post-discharge follow-up for discharged patients in line with TOC/TCM requirements.
• Conduct outreach via phone, telehealth, and in-clinic visits to educate patients on preventive care and chronic disease management.
• Document interactions and outcomes per CMS and organizational policies.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.

Skills

Care coordination

Patient education

Communication

Team collaboration

Education

ADN/BSN

FL RN license

3+ years nursing

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

Conviva Senior Primary Care seeks a Clinical Care Nurse (RN) to support safe transitions of care and improve Medicare Advantage Stars and quality performance. The clinic-based role involves proactive patient outreach, care coordination, and education across TOC and post-discharge processes.

Ideal candidates will analyze data from Athena EMR and other tools, coordinate follow-ups, and collaborate with providers and care teams to prevent readmissions and enhance patient outcomes.