RN Care Navigator: Transitions & Quality

CenterWell Senior Primary Care; Orlando (FL); On-site; USD 71,100 - 97,800; Full time

Job summary

The Clinical Care Nurse (RN) at CenterWell Senior Primary Care is a clinic-based role focused on improving patient outcomes through safe transitions of care and quality-driven interventions. You will support TOC, reduce avoidable ED visits, and contribute to Medicare Advantage Stars and CMS quality metrics.

Based in Orlando, FL, this in-center position emphasizes patient education, data-informed care, and collaboration with interdisciplinary teams to close care gaps and enhance chronic disease

Qualifications

• ADN or BSN nursing degree required.
• Active, unrestricted RN license (state-specific).
• 3+ years' clinical nursing experience with care transitions or population health.
• Proficiency with EHRs and data analytics tools listed.
• Willing to maintain Basic Life Support training.

Responsibilities

• Support care transitions and post-discharge follow-up to reduce readmissions.
• Analyze clinical data to identify gaps in Stars and HEDIS measures.
• Outreach via phone, telehealth, and in-clinic visits for preventive care
• Educate patients on chronic disease management and medications.
• Collaborate with interdisciplinary teams to implement interventions.
• Document outreach, interactions, and outcomes accurately per CMS standards.

Skills

RN clinical nursing

Data analysis

Communication

Patient education

Education

Associate’s degree in nursing (ADN) or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

The Clinical Care Nurse (RN) at CenterWell Senior Primary Care is a clinic-based role focused on improving patient outcomes through safe transitions of care and quality-driven interventions. You will support TOC, reduce avoidable ED visits, and contribute to Medicare Advantage Stars and CMS quality metrics.

Based in Orlando, FL, this in-center position emphasizes patient education, data-informed care, and collaboration with interdisciplinary teams to close care gaps and enhance chronic disease