Clinical Care RN: Transitions & Quality Improvement

CenterWell Senior Primary Care; Decatur (GA); On-site; USD 71,100 - 97,800; Full time

Job summary

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) in a clinic setting to improve patient outcomes through safe transitions of care and quality performance. This role supports Medicare Advantage Stars and drives evidence-based interventions.

Expect data-driven outreach and collaboration with the care team to enhance patient health and satisfaction. The position emphasizes direct patient education, post-discharge follow-up, and alignment with CMS standards while balancing

Qualifications

• ADN or BSN in nursing and active RN license.
• 3+ years of clinical nursing with exposure to transitions of care or population health.
• Proficiency with EMR and data analytics tools; MS Office.

Responsibilities

• Analyze clinical data to identify gaps in care related to Stars and HEDIS.
• Coordinate post-discharge follow-up per TOC/TCM to prevent readmissions.
• Outreach to educate patients and providers on preventive care and chronic disease management.
• Document outreach and care interactions in EMR per CMS standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions.
• Support clinic operations and participate in quality improvement projects.

Skills

Clinical nursing

TOC experience

Quality improvement

Data analysis

Patient education

Bilingual: English/Spanish

Education

Associate's degree in nursing (ADN)

Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office Suite

Job description

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) in a clinic setting to improve patient outcomes through safe transitions of care and quality performance. This role supports Medicare Advantage Stars and drives evidence-based interventions.

Expect data-driven outreach and collaboration with the care team to enhance patient health and satisfaction. The position emphasizes direct patient education, post-discharge follow-up, and alignment with CMS standards while balancing