RN Care Navigator — Transitions & Medicare Stars

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

Benefits offered by this job

Medical, dental, vision benefits

401(k) retirement plan

Paid time off

Job summary

CenterWell Senior Primary Care is seeking an experienced Clinical Care RN (RN) to operate clinic-based, driving transitions of care, quality initiatives, and Medicare Advantage Stars performance. The role emphasizes proactive patient and provider outreach, education, and data-driven care optimization.

Located in Arizona, this in-center position requires an active ARIZONA RN license, 3+ years of relevant clinical nursing experience, and strong EMR/data analytics proficiency to improve patient

Qualifications

• Associate degree in nursing (ADN) or Bachelor in Nursing (BSN) as a minimum requirement.
• Active, unrestricted RN license in the State of Arizona.
• 3+ years of clinical nursing with exposure to transitions of care, quality improvement, 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 (BLS).

Responsibilities

• Support transitions of care, post-discharge follow-up, and readmission prevention.
• Identify care opportunities and engage patients and providers.
• Deliver education on preventive care and chronic disease management.
• Coordinate outreach via phone, telehealth, and in-clinic visits.
• Document outreach and outcomes in line with CMS and organizational standards.
• Participate in center huddles, high-risk rounds, and quality improvement activities.

Skills

RN license

Clinical nursing

Data analysis

Athena EMR

Communication

Bilingual English/Spanish

Education

ADN

BSN

Tools

Athena EMR

DataHub

SalesForce HealthCloud

Compass Rose

Microsoft Office

Job description

CenterWell Senior Primary Care is seeking an experienced Clinical Care RN (RN) to operate clinic-based, driving transitions of care, quality initiatives, and Medicare Advantage Stars performance. The role emphasizes proactive patient and provider outreach, education, and data-driven care optimization.

Located in Arizona, this in-center position requires an active ARIZONA RN license, 3+ years of relevant clinical nursing experience, and strong EMR/data analytics proficiency to improve patient