Clinical Care RN: Transitions & Quality Impact

Conviva Senior Primary Care; Portland (TX); On-site; USD 60,000 - 90,000; Full time

Job summary

Conviva Senior Primary Care is seeking a Clinical Care Nurse (RN) to improve patient outcomes by coordinating safe transitions of care and post-discharge follow-up. Support for CMS quality initiatives and Stars performance will be a core focus.

The role involves analyzing data from Athena EMR and DataHub, conducting outreach by phone, telehealth and in-clinic visits, and collaborating with providers to prevent avoidable readmissions and ED visits while enhancing patient engagement and chronic

Qualifications

• Licensed registered nurse (RN) required.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS measures and transitions of care.
• Coordinate timely post-discharge follow-up to address readmission risks and TOC/TCM requirements.
• Conduct targeted outreach via phone, telehealth, and in-clinic visits to educate on preventive care and chronic disease management.
• Collaborate with interdisciplinary teams to implement interventions and improve workflows.
• Document outreach efforts and clinical interactions in accordance with CMS standards.

Skills

RN license

Care coordination

Post-discharge follow-up

Tools

Athena EMR

DataHub

Job description

Conviva Senior Primary Care is seeking a Clinical Care Nurse (RN) to improve patient outcomes by coordinating safe transitions of care and post-discharge follow-up. Support for CMS quality initiatives and Stars performance will be a core focus.

The role involves analyzing data from Athena EMR and DataHub, conducting outreach by phone, telehealth and in-clinic visits, and collaborating with providers to prevent avoidable readmissions and ED visits while enhancing patient engagement and chronic