Clinical Care Nurse, RN

CenterWell Senior Primary Care

Clinical Care Nurse (RN) improving patient outcomes through safe Transitions of Care at CenterWell. Focused on Medicare Advantage Stars ratings and quality performance.

Posted 7/29/2026full-timeChesapeake • Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $71,100 - $97,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical data analysis, care coordination, and patient engagement, with a strong focus on improving outcomes related to Stars and HEDIS measures. Proficient in utilizing electronic health records and data analytics tools to enhance transitional care management and support quality improvement initiatives.

Highest-signal resume keywords

Clinical Data AnalysisTransitional Care ManagementElectronic Health Records (EHR)Care CoordinationBilingual (Spanish and English)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Nursing ExperienceData Analytics ToolsMedication ManagementChronic Disease ManagementPatient Outreach

Soft Skills

CollaborationCommunicationProblem-Solving

Tools & Technologies

Athena EMRDataHubSalesForce HealthCloud

Certifications & Qualifications

Active RN LicenseAssociate's Degree in Nursing (ADN)Bachelor's Degree in Nursing (BSN)

Industry Keywords

Stars MeasuresHEDIS MeasuresTransitions of CareQuality ImprovementPopulation Health Management

About the role

Key responsibilities & impact

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 addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits.
Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence.
Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization.
Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows.
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.
Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Support clinic operations through provider collaboration, care coordination, and community education initiatives.
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.
Maintain patient confidentiality in accordance with HIPAA.
Document patient encounters accurately and timely in the indicated platform (e.g., medical record).
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.

Requirements

What you’ll need

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)
Proficient in both Spanish and English.

Benefits

Comp & perks

medical, dental and vision benefits
401(k) retirement savings plan
time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
short-term and long-term disability
life insurance and many other opportunities