Clinical Care RN: Transitions & Quality Improvement

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

Job summary

CenterWell Senior Primary Care is hiring a Clinical Care RN (Clinic-based) to support Transitions of Care, reduce avoidable ED visits, and drive Medicare Stars and quality performance. You will balance patient education with data-driven improvements, collaborating across interdisciplinary teams in a clinic setting.

The role focuses on post-discharge follow-up, care coordination, and evidence-based interventions to improve outcomes and patient engagement.

Qualifications

• RN license in South Carolina (active and unrestricted).
• Degree in nursing (ADN or BSN).
• 3+ years of clinical nursing with transitions of care, quality improvement, managed care, or population health management.
• Experience with Athena EMR and data analytics tools (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.
• Coordinate timely post-discharge follow-up in alignment with TOC and TCM.
• Outreach via phone, telehealth and in-clinic visits to educate on preventive and chronic disease management.
• Assess discharge understanding and ensure adherence to follow-up appointments.
• Collaborate with providers and care team to implement evidence-based interventions.
• Document outreach and interactions accurately per CMS standards.
• Participate in center huddles and high-risk rounds with the team.
• Support quality improvement projects and provider education sessions.

Skills

RN license SC

Clinical nursing experience

Bilingual EN/ES

Motivational interviewing

Communication skills

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

MS Office

Job description

CenterWell Senior Primary Care is hiring a Clinical Care RN (Clinic-based) to support Transitions of Care, reduce avoidable ED visits, and drive Medicare Stars and quality performance. You will balance patient education with data-driven improvements, collaborating across interdisciplinary teams in a clinic setting.

The role focuses on post-discharge follow-up, care coordination, and evidence-based interventions to improve outcomes and patient engagement.