Clinical Care RN: Transitions of Care & Quality Impact

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

Job summary

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) to support safe Transitions of Care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance. This clinic-based role emphasizes education, data-driven quality improvement, and teamwork across providers and care teams.

The RN will analyze data from Athena EMR and DataHub, coordinate post-discharge follow-ups, and balance patient education with outreach to close care gaps.

Qualifications

• Must have ADN or BSN nursing degree and active RN license in VA.
• 3+ years of clinical nursing experience with transitions of care, quality improvement, or population health.
• Proficiency with EMR and data analytics tools; willingness to maintain BLS.

Responsibilities

• Analyze clinical data to identify gaps in care related to Stars and HEDIS.
• Coordinate post-discharge follow-up to prevent readmissions and ED visits.
• Outreach to patients and providers via phone, telehealth, and in-clinic visits for education and care opportunities.
• Document outreach and outcomes accurately per CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions.
• Participate in center huddles and quality improvement initiatives.
• Monitor progress toward Stars and TCM goals and address barriers.
• Support clinic operations through care coordination and community education.

Skills

Transitions of Care coordination

Data analysis

Communication skills

Nursing clinical judgment

Education

ADN or BSN nursing degree

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) to support safe Transitions of Care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance. This clinic-based role emphasizes education, data-driven quality improvement, and teamwork across providers and care teams.

The RN will analyze data from Athena EMR and DataHub, coordinate post-discharge follow-ups, and balance patient education with outreach to close care gaps.