Clinical Care RN: Transitions & Quality Improvement

CenterWell Senior Primary Care; Grand Prairie (TX); On-site; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits

Job summary

CenterWell Senior Primary Care seeks a Clinical Care Nurse (RN) to support Transitions of Care and drive Medicare Advantage Stars improvements in a clinic setting. The role involves post-discharge follow-ups, patient and provider outreach, and data-driven quality initiatives.

The ideal candidate has Texas RN licensure, 3+ years of clinical nursing experience, and proficiency with Athena EMR and data tools. In-center work with opportunities for collaboration and ongoing education.

Qualifications

• ADN or BSN required.
• Active, unrestricted RN license in Texas.
• 3+ years clinical nursing experience 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 MS Office.
• 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.
• Coordinate timely post-discharge follow-up for TOC/TCM needs.
• Conduct targeted outreach via phone, telehealth and in-clinic visits to educate on preventive care and chronic disease management.
• Document outreach, clinical interactions and outcomes per CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Participate in quality improvement projects and center huddles to stay current with guidelines.

Skills

RN license

Clinical nursing

Data analysis

Communication

Patient education

Education

ADN/BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care seeks a Clinical Care Nurse (RN) to support Transitions of Care and drive Medicare Advantage Stars improvements in a clinic setting. The role involves post-discharge follow-ups, patient and provider outreach, and data-driven quality initiatives.

The ideal candidate has Texas RN licensure, 3+ years of clinical nursing experience, and proficiency with Athena EMR and data tools. In-center work with opportunities for collaboration and ongoing education.