Clinical Care RN: Transitions & Quality Improvement

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

Job summary

CenterWell is seeking a Clinical Care Nurse (RN) to support Transitions of Care and improve Medicare Advantage Stars and quality performance. You will educate patients, coordinate post-discharge follow-ups, and work with a multidisciplinary team to reduce avoidable ED visits and readmissions.

The role requires in-clinic presence in South Carolina, with a focus on DM, HTN, CHF, and COPD management, aligning with organizational values of integrity, respect, empathy, and health equity.

Qualifications

• Associate or bachelor’s degree in nursing is required.
• Active, unrestricted RN license in the State of South Carolina.
• 3+ years of clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with electronic health records and data analytics tools, and Microsoft Office Suite.
• Willingness 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 post-discharge follow-up to address readmissions and ED utilization.
• Outreach to patients and providers via phone, telehealth, and in-clinic visits to educate on preventive care and chronic disease management.
• Document outreach efforts and outcomes in accordance with CMS and organizational standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Participate in center huddles, high-risk rounds, and quality improvement activities.

Skills

RN license

Clinical nursing

Data analysis

Communication skills

EHR systems

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell is seeking a Clinical Care Nurse (RN) to support Transitions of Care and improve Medicare Advantage Stars and quality performance. You will educate patients, coordinate post-discharge follow-ups, and work with a multidisciplinary team to reduce avoidable ED visits and readmissions.

The role requires in-clinic presence in South Carolina, with a focus on DM, HTN, CHF, and COPD management, aligning with organizational values of integrity, respect, empathy, and health equity.