RN Care Transitions & Quality Advocate

CenterWell; Las Vegas (NV); On-site; USD 71,000 - 98,000; Full time

Job summary

CenterWell Senior Primary Care in Las Vegas, NV seeks a Clinical Care RN to support transitions of care, reduce readmissions, and advance Medicare Advantage Stars through education and data-driven quality improvement. This clinic-based, full-time role requires an active RN license and ADN or BSN with 3+ years of relevant experience.

You will analyze care gaps using Athena EMR and DataHub, coordinate post-discharge follow-up, educate patients, and collaborate with providers to improve outcomes

Qualifications

• Associate’s degree in nursing (ADN) OR Bachelor's degree in nursing (BSN).
• Active, unrestricted RN license (state specific as applicable).
• 3+ years’ clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, Salesforce HealthCloud – per your prior employer’s population health tools), and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.
• Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements.
• Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.
• Document outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
• Collaborate effectively with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.

Skills

RN licensure

Clinical nursing

Care coordination

Data analysis

Communication

Bilingual English/Spanish

Education

Associate’s degree in nursing

Bachelor’s degree in nursing

Tools

Athena EMR

DataHub

Compass Rose

Salesforce Health Cloud

Microsoft Office

Job description

CenterWell Senior Primary Care in Las Vegas, NV seeks a Clinical Care RN to support transitions of care, reduce readmissions, and advance Medicare Advantage Stars through education and data-driven quality improvement. This clinic-based, full-time role requires an active RN license and ADN or BSN with 3+ years of relevant experience.

You will analyze care gaps using Athena EMR and DataHub, coordinate post-discharge follow-up, educate patients, and collaborate with providers to improve outcomes