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, Medicare Advantage Stars, Patient education, EHR proficiency. Analyze clinical data and trends. Identify gaps in care”
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 return visits; Close care opportunities; Improve clinical performance; Improve patient engagement
Industry & Context.
Data analysis skills; Problem-solving
Must reside in designated market area, Valid state driver's license, Maintain personal vehicle liability insurance, TB screening required, Occasional travel within the market
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, Bilingual in English and Spanish with full professional proficiency, Basic Life Support trained
What You'll Do.
Analyze clinical data and trends
Identify gaps in care
Coordinate post-discharge follow-up
Conduct patient and provider outreach
Provide tailored education
Conduct post-discharge outreach
Assess understanding of discharge instructions
Identify and escalate barriers
Collaborate with providers and care team
Document outreach efforts and outcomes
Prepare and discuss patients in huddles
Participate in quality improvement projects
Monitor progress toward Stars goals
Support clinic operations
Coordinate and facilitate Wellness Events
How You'll Work.
Team & Collaboration
Collaborate effectively with interdisciplinary teams; Collaborate with providers and care team; Collaborate with care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff; Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team; Provider 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: CW Groves, CW Riverview 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 aim of add
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