RN Care Continuum Specialist – Transitions & Quality

Jobtailor; Daytona Beach (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

Jobtailor is seeking an experienced registered nurse in Florida to lead transitions of care and care coordination across clinics. You will analyze data in Athena EMR and DataHub to identify care gaps, support post-discharge follow-up, and educate patients on chronic disease management.

Ideal candidates have 3+ years of nursing, an active Florida license, and experience with CMS quality requirements. The role emphasizes collaboration with providers and care teams and involves in-clinic,

Qualifications

• Active Florida RN license with no licensure holds.
• 3+ years’ clinical nursing experience, exposure to transitions of care or quality improvement.
• Proficiency with Athena EMR and data-analytics tools.
• Familiarity with Medicare Stars, HEDIS, and CMS requirements preferred.
• Must reside in the designated market area with reasonable commute.

Responsibilities

• Improve patient outcomes through clinic-based nursing care and care coordination.
• Support safe transitions of care and reduce ED utilization and readmissions.
• Analyze clinical data to identify gaps and prioritize actions.
• Coordinate post-discharge follow-up per TOC/TCM requirements.
• Conduct outreach by phone, telehealth, and in-clinic visits.
• Provide diabetes, hypertension, CHF, and COPD education.
• Document interactions accurately per CMS standards.

Skills

Active Florida RN

Clinical Nursing Experience

Athena EMR

Data Analytics

Medicare Stars knowledge

Education

ADN or BSN

Tools

DataHub

Salesforce HealthCloud

Microsoft Office Suite

Job description

Jobtailor is seeking an experienced registered nurse in Florida to lead transitions of care and care coordination across clinics. You will analyze data in Athena EMR and DataHub to identify care gaps, support post-discharge follow-up, and educate patients on chronic disease management.

Ideal candidates have 3+ years of nursing, an active Florida license, and experience with CMS quality requirements. The role emphasizes collaboration with providers and care teams and involves in-clinic,