RN Care Transitions & Quality Improvement Specialist

Conviva Senior Primary Care; San Antonio (TX); On-site; USD 71,000 - 98,000; Full time

Job summary

Conviva Senior Primary Care is seeking a Clinic-based Registered Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars. The role emphasizes data-driven quality improvement and collaboration with providers to enhance patient outcomes.

Responsibilities include post-discharge follow-up, education on preventive care and chronic disease management, and ensuring accurate documentation while maintaining HIPAA standards.

Qualifications

• Associate's degree in nursing (ADN) -OR- Bachelor's degree in nursing (BSN).
• Active, unrestricted RN license in the State of Texas.
• 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) and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS measures and TOC.
• Identify recently discharged patients and coordinate timely post-discharge follow-up.
• Outreach via phone, telehealth and in-clinic visits to educate on preventive care and chronic disease management.
• Post-discharge outreach to ensure understanding of discharge instructions and adherence to follow-ups.
• Collaborate with interdisciplinary teams to implement interventions and improve workflows.
• Document outreach, clinical interactions, and outcomes in the medical record.
• Participate in center huddles, high-risk rounds and quality improvement activities.
• Monitor progress toward Stars and TOC goals and develop solutions.

Skills

RN license (TX)

Clinical nursing

Transitions of Care

Data analysis

Motivational interviewing

Bilingual English/Spanish

Willing for BLS

Education

ADN

BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Job description

Conviva Senior Primary Care is seeking a Clinic-based Registered Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars. The role emphasizes data-driven quality improvement and collaboration with providers to enhance patient outcomes.

Responsibilities include post-discharge follow-up, education on preventive care and chronic disease management, and ensuring accurate documentation while maintaining HIPAA standards.