Transitional Care RN - Data-Driven Coordinator, Bilingual

Jobtailor; Chesapeake (VA); On-site; USD 85,000 - 110,000; Full time

Job summary

Jobtailor is seeking an experienced registered nurse focused on care coordination and population health management in Virginia. The role involves analyzing clinical data from Athena EMR and DataHub to close care gaps related to Stars and HEDIS measures and improving transitions of care.

You will proactively reach out to recently discharged patients, conduct education on preventive and chronic disease management, and document all activities in adherence with CMS guidelines.

Qualifications

• Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN) required.
• 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.

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 in line with TOC and TCM requirements.
• Conduct targeted outreach via phone, telehealth, and in-clinic visits to educate on preventive care and chronic disease management.
• Document outreach and clinical interactions accurately, in compliance with CMS standards.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.

Skills

Clinical nursing

Data analytics

Medication management

Chronic disease management

Patient outreach

Collaboration

Communication

Problem-solving

Bilingual (Spanish & English)

Education

Associate's degree in nursing (ADN)

Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

SalesForce HealthCloud

Job description

Jobtailor is seeking an experienced registered nurse focused on care coordination and population health management in Virginia. The role involves analyzing clinical data from Athena EMR and DataHub to close care gaps related to Stars and HEDIS measures and improving transitions of care.

You will proactively reach out to recently discharged patients, conduct education on preventive and chronic disease management, and document all activities in adherence with CMS guidelines.