Clinical Care RN: Transitions & Quality for Medicare Stars

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

Job summary

CenterWell Senior Primary Care in Mesa, AZ seeks a Clinical Care Nurse (RN) to improve patient outcomes through transitions of care, reduce avoidable ED visits, and support Medicare Advantage Stars and quality performance. This clinic-based role emphasizes education, outreach, and data-driven quality improvements in collaboration with the care team.

You will analyze clinical data from Athena EMR and other systems, coordinate post-discharge follow-ups, and educate patients on chronic disease

Qualifications

• Must have current RN license (state-specific).
• 3+ years of clinical nursing experience with exposure to transitions of care or population health.
• Proficiency with EHRs and data analytics tools; basic Life Support.
• Willingness to complete and maintain BLS training.

Responsibilities

• Analyze clinical data to identify gaps related to Stars and HEDIS measures and TOC.
• Coordinate post-discharge follow-up and ensure timely outreach.
• Educate patients and providers on preventive care, chronic disease management, and medication management.

Skills

RN license

Clinical nursing experience

Data analysis

Education in nursing (ADN/BSN)

Education

Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care in Mesa, AZ seeks a Clinical Care Nurse (RN) to improve patient outcomes through transitions of care, reduce avoidable ED visits, and support Medicare Advantage Stars and quality performance. This clinic-based role emphasizes education, outreach, and data-driven quality improvements in collaboration with the care team.

You will analyze clinical data from Athena EMR and other systems, coordinate post-discharge follow-ups, and educate patients on chronic disease