Clinical Care Nurse, RN

CenterWell Senior Primary Care

. Support safe Transitions of Care, reduce avoidable emergency department utilization, and improve Medicare Advantage Stars and quality performance .

Posted 10/30/2026full-timePeoria • Arizona • United StatesMid-LevelSenior💰 $71,100 - $97,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical nursing with a focus on Transitions of Care, quality improvement, and patient-centered care. Proficient in data analysis and electronic health records, ensuring compliance with Medicare Advantage Stars and HEDIS standards.

Highest-signal resume keywords

Active RN License in ArizonaClinical Nursing Experience (3+ Years)Proficiency with Athena EMRKnowledge of Medicare Advantage Stars and HEDISStrong Clinical Judgment

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical NursingData AnalysisMedication ReconciliationSymptom MonitoringEvidence-Based PracticesTransitions of CareQuality ImprovementChronic Disease ManagementPatient EducationCare Coordination

Soft Skills

Excellent CommunicationMotivational InterviewingCommitment to Health EquityInterdisciplinary CollaborationProblem-Solving

Tools & Technologies

Athena EMRDataHubSalesforce HealthCloudMicrosoft Office Suite

Certifications & Qualifications

Associate’s Degree in Nursing (ADN)Bachelor’s Degree in Nursing (BSN)Basic Life Support Training

Industry Keywords

Transitions of CareMedicare AdvantageHEDISCMS Quality RequirementsPatient-Centered CareHealth EquityManaged CarePopulation Health Management

About the role

Key responsibilities & impact

Support safe Transitions of Care, reduce avoidable emergency department utilization, and improve Medicare Advantage Stars and quality performance
Analyze clinical data and trends in Athena EMR, DataHub, and related platforms to identify Stars, HEDIS, and post-hospitalization care gaps
Identify recently discharged inpatient, observation, and emergency department patients
Coordinate timely post-discharge follow-up in alignment with TOC and TCM requirements
Conduct patient and provider outreach by phone, telehealth, and in-clinic visits
Provide education on preventive care, chronic disease management, and medication management
Perform post-discharge assessment, medication reconciliation, symptom monitoring, and follow-up appointment adherence checks
Identify and escalate barriers to care and collaborate with providers and care teams to prevent readmissions and avoidable ED utilization
Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows
Document outreach, clinical interactions, encounters, and outcomes accurately in compliance with organizational and CMS standards
Participate in center huddles and high-risk rounds
Participate in quality improvement projects and provider education sessions
Monitor Stars and Transitional Care Management goals and develop solutions to improve performance and patient engagement
Support clinic operations through provider collaboration, care coordination, and community education
Coordinate and facilitate center and market-based wellness events
Maintain patient confidentiality in accordance with HIPAA
Follow safety, infection control, and attendance policies
Travel quarterly within the market to alternative clinics for strategic meetings

Requirements

What you’ll need

Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN)
Active, unrestricted RN license in the State of Arizona
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management
Proficiency with electronic health records such as Athena EMR
Proficiency with data analytics tools such as DataHub, Compass Rose, and Salesforce HealthCloud
Proficiency with Microsoft Office Suite
Willing and able to complete and maintain Basic Life Support training
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements
Experience with Transitions of Care, hospital discharge, or ER follow-up programs
Strong clinical judgment and data analysis skills
Ability to apply evidence-based practices
Excellent communication and motivational interviewing skills
Commitment to health equity, inclusiveness, and patient-centered care
Valid state driver's license
Personal vehicle liability insurance meeting applicable requirements
Must reside in the designated market area within reasonable commuting distance of assigned clinics
Ability to work Monday–Friday, 8:00 AM–5:00 PM, with additional time as required

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical benefits
Dental benefits
Vision benefits
401(k) retirement savings plan
Paid time off
Company holidays
Personal holidays
Paid parental leave
Paid caregiver leave
Short-term disability
Long-term disability
Life insurance
Personal wellness support
TB screening program
Professional growth opportunities