Clinic-Based RN: Transitions, Quality & Care Impact

CenterWell Senior Primary Care; Richardson (TX); On-site; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Disability and life insurance

Job summary

CenterWell Senior Primary Care is hiring a Clinical Care Nurse (RN) to support safe transitions of care, reduce readmissions, and improve Medicare Advantage Stars performance. You will balance patient education with data-driven quality initiatives in a clinic-based role in the Dallas/DFW Richardson area.

The role requires an active Texas RN license and 3+ years of nursing experience, with proficiency in Athena EMR and data tools.

Qualifications

• Active RN license in Texas or eligibility for licensure in-state.
• 3+ years of clinical nursing experience with care transitions or population health.
• Proficiency with Athena EMR, DataHub, Compass Rose, Salesforce HealthCloud and MS Office.
• Willing to complete Basic Life Support training.

Responsibilities

• Analyze data to identify gaps in care related to Stars and HEDIS and TOC.
• Identify recently discharged patients and coordinate timely post-discharge follow-up.
• Outreach by phone, telehealth and in-clinic visits for education on preventive care.
• Assess discharge instructions, medication reconciliation and follow-up adherence.
• Collaborate with providers and care teams to implement interventions.
• Document all outreach and clinical interactions in the medical record per CMS rules.
• Participate in center huddles and quality improvement activities.
• Monitor Stars and Transitional Care Management goals and address barriers.

Skills

RN with 3+ years clinical nursing

Data analysis

EHR proficiency

Patient education

Interdisciplinary collaboration

Education

Associate's degree in nursing (ADN)

Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care is hiring a Clinical Care Nurse (RN) to support safe transitions of care, reduce readmissions, and improve Medicare Advantage Stars performance. You will balance patient education with data-driven quality initiatives in a clinic-based role in the Dallas/DFW Richardson area.

The role requires an active Texas RN license and 3+ years of nursing experience, with proficiency in Athena EMR and data tools.