Clinical Care RN: Transitions & Quality Improvement

CenterWell; Columbia (SC); On-site; USD 71,000 - 98,000; Full time

Job summary

CenterWell seeks a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED utilization, and drive Medicare Advantage quality performance in a clinic-based setting.

The RN will analyze data from Athena EMR and DataHub, coordinate post-discharge follow-ups, educate patients, and collaborate with providers to close care gaps and improve outcomes. This role requires SC RN license and ADN/BSN with 3+ years of nursing experience.

Qualifications

• Must have ADN or BSN nursing degree.
• Active, unrestricted RN license in South Carolina.
• 3+ years of clinical nursing with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, Salesforce HealthCloud), and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS measures and Transitions of Care.
• Proactively identify recently discharged patients and coordinate timely post-discharge follow-up.
• Conduct targeted outreach via phone, telehealth and in-clinic visits to close care opportunities and educate on preventive care and medication management.
• Document outreach efforts and clinical interactions accurately in CMS-compliant systems.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Participate in quality improvement projects and provider education sessions.

Skills

Clinical nursing

Transitions of care

Patient education

Collaboration

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 seeks a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED utilization, and drive Medicare Advantage quality performance in a clinic-based setting.

The RN will analyze data from Athena EMR and DataHub, coordinate post-discharge follow-ups, educate patients, and collaborate with providers to close care gaps and improve outcomes. This role requires SC RN license and ADN/BSN with 3+ years of nursing experience.