Clinical Care RN: Transitions & Quality Leader

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

Job summary

CenterWell Senior Primary Care in Columbia, SC seeks an experienced Clinical Care RN to support safe transitions of care and improve Medicare Advantage Stars and quality performance. You will balance direct patient education with data-driven improvement, coordinating post-discharge follow-up and timely outreach in collaboration with the care team.

In this clinic-based role, you will analyze trends in CMS measures, engage patients and providers, document interactions, and contribute to weekly

Qualifications

• Must hold ADN or BSN nursing degree.
• Active, unrestricted RN license in 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, data analytics tools, and Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data in EMR and data platforms to identify gaps in Stars/HEDIS and Transitions of Care.
• Proactively identify recently discharged patients and coordinate timely post-discharge follow-up per TOC/TCM requirements.
• Conduct targeted patient and provider outreach to educate on preventive care, chronic disease management, and medication management.
• Assess discharge instructions, reconcile medications, monitor symptoms, and ensure follow-up adherence to reduce readmissions.
• Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy and QA staff to implement interventions and optimize workflows.
• Document all outreach, interactions and outcomes accurately per CMS and organizational standards.
• Participate in center huddles, high-risk rounds, and quality improvement activities.
• Monitor progress toward Stars and TCM goals, identify barriers, and develop solutions with the team.
• Support clinic operations and community education initiatives.

Skills

EHR proficiency

Data analytics

MS Office

BLS

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care in Columbia, SC seeks an experienced Clinical Care RN to support safe transitions of care and improve Medicare Advantage Stars and quality performance. You will balance direct patient education with data-driven improvement, coordinating post-discharge follow-up and timely outreach in collaboration with the care team.

In this clinic-based role, you will analyze trends in CMS measures, engage patients and providers, document interactions, and contribute to weekly