Centerwell Senior Primary Care
Healthcare
ClinicalCareNurse(RN)
Neural analysis suggests this role is
optimal for Mid candidates.
“Clinical Care Nurse (RN) at Centerwell Senior Primary Care. Skills: Transitions of Care, Quality Improvement, Patient Education, EHR Proficiency. Support safe Transitions of Care (TOC). Reduce avoidable ED utilization”
What You'll Achieve.
Improve patient outcomes; Reduce avoidable ED utilization; Drive Medicare Advantage Stars and quality performance; Enhance patient health outcomes and satisfaction; Prevent avoidable readmissions; Prevent avoidable ED utilization; Optimize workflows; Improve clinical performance; Improve patient engagement; Achieve Stars care opportunity closures
Industry & Context.
Clinical judgment; Data analysis skills
Must reside in designated market area, Valid state driver's license, Maintain personal vehicle liability insurance, TB screening required, Patient facing role
What They're Looking For.
Must Have
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
Nice to Have
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements, Experience with Transitions of Care, hospital discharge or ER follow up programs, clinical judgment, data analysis skills, and ability to apply evidence-based practices, Excellent communication and motivational interviewing skills to educate and empower members, Commitment to health equity, inclusiveness, and patient-centered care, Basic Life Support trained
What You'll Do.
Support safe Transitions of Care (TOC)
Reduce avoidable ED utilization
Drive Medicare Advantage Stars and quality performance
Proactively identify care opportunities
Engage patients and providers
Drive evidence-based interventions
Balance direct patient education and outreach
Analyze clinical data and trends
Coordinate timely post-discharge follow-up
Conduct targeted patient and provider outreach
Provide tailored education
Conduct post-discharge outreach
Assess understanding of discharge instructions
Perform medication reconciliation
Monitor follow-up appointment adherence
Collaborate with providers and care team
Document all outreach efforts
Document clinical interactions
Prepare and discuss patients in center huddles
Participate in high-risk rounds
Participate in quality improvement projects
Participate in provider education sessions
Monitor progress toward Stars goals
Monitor Transitional Care Management goals
Support clinic operations
Facilitate center and market-based Wellness Events
Maintain patient confidentiality
Document patient encounters
Follow organizational policies
How You'll Work.
Team & Collaboration
Collaborate effectively with interdisciplinary teams; Collaborate with providers; Collaborate with care assistants; Collaborate with center administrators; Collaborate with medical assistants; Collaborate with pharmacy; Collaborate with quality improvement staff; Collaborate with providers and care team; Collaborate with center-based and interdisciplinary team; Provider collaboration; Cross-functional collaboration
Communication Scope
Excellent communication; Motivational interviewing skills
Full Job Description
# **Become a part of our caring community** The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. You will support safe Transitions of Care (TOC), reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes. CenterWell/Conviva clinic locations may be available in the following areas: Grove Park, Greenbriar As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity – to enhance patient health outcomes and satisfaction. **Role Scope** * Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients. * Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population. * Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD. **Duties and 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, with the
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