Clinical Care RN - Transitions & Quality Advocate

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

Benefits offered by this job

Medical benefits

401(k) plan

Paid time off

Wellness program

Job summary

CenterWell Senior Primary Care seeks a Clinical Care RN to support safe transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars performance. The role emphasizes patient education, data-driven quality improvement, and collaboration with providers within the clinic network.

The RN will analyze data, coordinate post-discharge follow-ups, and lead targeted outreach to close care gaps while maintaining HIPAA compliance and patient-centered care principles.

Qualifications

• Must hold an RN license (state-specific).
• 3+ years’ clinical nursing experience with transitions of care or population health.
• Proficiency with electronic health records and data analytics tools.
• Willing to complete Basic Life Support training.

Responsibilities

• Analyze clinical data to identify gaps in care related to Stars and HEDIS measures.
• Coordinate timely post-discharge follow-ups per TOC/TCM.
• Conduct outreach via phone, telehealth, and in-clinic visits for education and care opportunities.
• Assess discharge instructions and med reconciliation to prevent readmissions.
• Collaborate with interdisciplinary team to implement evidence-based interventions.
• Document interactions and outcomes per CMS standards.

Skills

RN with ADN/BSN

Active RN license

3+ years clinical nursing

Athena EMR

Data analytics tools

MS Office

Education

ADN/BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care seeks a Clinical Care RN to support safe transitions of care, reduce avoidable ED visits, and improve Medicare Advantage Stars performance. The role emphasizes patient education, data-driven quality improvement, and collaboration with providers within the clinic network.

The RN will analyze data, coordinate post-discharge follow-ups, and lead targeted outreach to close care gaps while maintaining HIPAA compliance and patient-centered care principles.