Conviva Senior Primary Care
Healthcare
ClinicalCareNurse(RN)
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optimal for Mid candidates.
“Clinical Care Nurse (RN) at Conviva Senior Primary Care. Skills: Transitions of Care, Quality Improvement, Patient Education, EHR Proficiency. Analyze clinical data to identify gaps in care. Coordinate timely post-discharge follow-up”
What You'll Achieve.
Improve patient outcomes; Reduce avoidable ED utilization; Drive Medicare Advantage Stars ratings; Drive quality performance; Enhance patient health outcomes; Enhance patient satisfaction; Prevent avoidable readmissions; Prevent return visits; Close care opportunities; Optimize workflows; Improve clinical performance; Improve patient engagement
Industry & Context.
Data analysis skills; Identify barriers; Develop innovative solutions
Must reside in designated market area, Valid state driver's license, Maintain personal vehicle liability insurance, TB screening required, In-center presence 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, 3+ years' clinical nursing experience, Bilingual in English and Spanish with full professional proficiency, Proficiency with electronic health records, Proficiency with data analytics tools, Proficiency with Microsoft Office Suite, Willing and able to complete and maintain Basic Life Support training
Nice to Have
Knowledge of Medicare Advantage Stars, Knowledge of HEDIS, Knowledge of CAHPS, Knowledge of CMS quality requirements, Experience with Transitions of Care, Experience with hospital discharge follow up programs, Experience with ER follow up programs, Clinical judgment, Data analysis skills, Ability to apply evidence-based practices, Excellent communication skills, Motivational interviewing skills, Commitment to health equity, Commitment to inclusiveness, Commitment to patient-centered care, Basic Life Support trained
What You'll Do.
Analyze clinical data to identify gaps in care
Coordinate timely post-discharge follow-up
Conduct targeted patient and provider outreach
Conduct post-discharge outreach to assess understanding
Collaborate effectively with interdisciplinary teams
Document all outreach efforts and clinical interactions
Prepare and discuss patients in center huddles
Participate in quality improvement projects
Monitor progress toward Stars and TCM goals
Support clinic operations
Facilitate center and market-based Wellness Events
Maintain patient confidentiality
Document patient encounters accurately
Follow organizational policies
How You'll Work.
Team & Collaboration
Collaborate effectively with interdisciplinary teams; Collaborate with providers and care team; Collaborate with center administrators; Collaborate with medical assistants; Collaborate with pharmacy; Collaborate with quality improvement staff; Collaborate with providers in center huddles; Collaborate with the center-based team; Collaborate with the interdisciplinary team; Collaborate with providers for care coordination
Communication Scope
Excellent communication skills; Motivational interviewing skills
Process & Methodology
Quality improvement projects
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. Conviva clinic locations may be available in the following areas: CON Belle Glade, CON Everglades 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 ai
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