Clinical Care RN: Transitions of Care & Quality

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

Job summary

CenterWell Senior Primary Care seeks an in-clinic Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The role focuses on proactive follow-up, patient education, and data-driven improvements across the care continuum.

You will work with interdisciplinary teams in Indiana to identify care opportunities, balance direct patient education with outreach, and document outcomes in compliance with CMS

Qualifications

• RN license in Indiana (unrestricted).
• 3+ years of clinical nursing experience with exposure to transitions of care or population health.
• Proficiency with electronic health records (Athena EMR) and data tools (DataHub, Compass Rose, SalesForce HealthCloud).
• Willingness to complete Basic Life Support training.

Responsibilities

• Coordinate TOC and post-discharge follow-up to prevent readmissions and ED visits.
• Educate patients on preventive care, chronic disease management and medication use.
• Document outreach and clinical interactions accurately in the EHR and CMS-compliant systems.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and improve workflows.
• Participate in quality improvement initiatives and center huddles to align with organizational priorities.

Skills

RN license Indiana

3+ years clinical nursing

Data analytics

Effective communication

Bilingual English/Spanish

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care seeks an in-clinic Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The role focuses on proactive follow-up, patient education, and data-driven improvements across the care continuum.

You will work with interdisciplinary teams in Indiana to identify care opportunities, balance direct patient education with outreach, and document outcomes in compliance with CMS