RN Clinical Care: Elevate Transitions & Quality

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

Job summary

CenterWell in Las Vegas, NV is seeking a Clinical Care Nurse (RN) to support transitions of care, reduce avoidable ED use, and drive Medicare Advantage Stars and quality performance.

This clinic-based role requires ADN or BSN, NV RN license, and 3+ years of clinical nursing experience. You will work with Athena EMR and data tools to identify gaps, educate patients, and partner with providers to improve outcomes.

Qualifications

• Must hold an ADN or BSN in nursing.
• Active, unrestricted RN license in Nevada.
• 3+ years of clinical nursing with transitions of care exposure.
• Proficiency with Athena EMR, DataHub, Compass Rose, and Salesforce HealthCloud.
• Basic Life Support (BLS) certification.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS measures and transitions of care.
• Coordinate post-discharge follow-up for recently discharged patients per TOC/TCM requirements.
• Conduct targeted outreach via phone, telehealth, and in-clinic visits to educate on preventive care and chronic disease management.
• Assess understanding of discharge instructions and medication reconciliation to prevent readmissions.
• Collaborate with providers, care team, and administrative staff to implement evidence-based interventions and improve workflows.
• Document outreach and clinical interactions accurately per CMS and organizational standards.
• Participate in center huddles and high-risk rounds with the team to discuss patients.
• Engage in quality improvement projects and stay current with guidelines.
• Monitor Stars/TCM progress and develop solutions to barriers.

Skills

Nursing experience

Analytical thinking

Motivational interviewing

Interdisciplinary collaboration

HIPAA compliance

Education

ADN or BSN degree

Nevada RN license

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

CenterWell in Las Vegas, NV is seeking a Clinical Care Nurse (RN) to support transitions of care, reduce avoidable ED use, and drive Medicare Advantage Stars and quality performance.

This clinic-based role requires ADN or BSN, NV RN license, and 3+ years of clinical nursing experience. You will work with Athena EMR and data tools to identify gaps, educate patients, and partner with providers to improve outcomes.