Clinical Care RN: Transitions & Quality Advocate

CenterWell Certified Healthcare Corp.; Florida; On-site; USD 71,000 - 98,000; Full time

Job summary

CenterWell Certified Healthcare Corp. in Florida seeks a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars and quality performance.

This clinic-based role focuses on patient education, proactive outreach, and data-driven quality improvement. You will analyze clinical data from Athena EMR and other systems, perform post-discharge follow-ups, and coordinate with providers and the care team to close care gaps.

Qualifications

• RN license in Florida or active, unrestricted license.
• 3+ years' clinical nursing experience with transitions of care or population health.
• Bilingual in English and Spanish with full professional proficiency.
• Proficiency with EHR and data analytics tools listed.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS.
• Identify recently discharged patients and coordinate timely post-discharge follow-up.
• Outreach via phone, telehealth and in-clinic visits to close care opportunities.
• Assess understanding of discharge instructions and ensure adherence to follow-up.
• Collaborate with providers and care team to optimize workflows and outcomes.
• Document outreach, interactions, and outcomes per policies and CMS rules.

Skills

Clinical nursing

Bilingual English/Spanish

Communication skills

Patient education

Education

Associate's degree in nursing or Bachelor's degree in nursing

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell Certified Healthcare Corp. in Florida seeks a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars and quality performance.

This clinic-based role focuses on patient education, proactive outreach, and data-driven quality improvement. You will analyze clinical data from Athena EMR and other systems, perform post-discharge follow-ups, and coordinate with providers and the care team to close care gaps.