Clinical Care Nurse, RN

CenterWell Senior Primary Care

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

Posted 11/5/2026full-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 nursing with a focus on Transitions of Care, quality improvement, and care coordination. Proficient in data analysis and electronic health records, with strong communication skills to engage patients and providers effectively.

Highest-signal resume keywords

Active RN LicenseClinical Nursing ExperienceProficiency With Athena EMRData Analysis SkillsBilingual English And Spanish

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical NursingData AnalysisMedication ManagementChronic Disease ManagementTransitions Of CareQuality ImprovementPatient OutreachSymptom MonitoringMedication ReconciliationEvidence-Based Practices

Soft Skills

Excellent CommunicationMotivational InterviewingCollaborationProblem-SolvingPatient Education

Tools & Technologies

Athena EMRDataHubSalesForce HealthCloudMicrosoft Office Suite

Certifications & Qualifications

Basic Life Support TrainingRN License

Industry Keywords

Medicare Advantage StarsHEDISCAHPSCMS Quality RequirementsCare CoordinationPopulation Health Management

About the role

Key responsibilities & impact

Support safe Transitions of Care, reduce avoidable ED utilization, and improve Medicare Advantage Stars and quality performance
Analyze clinical data and trends from Athena EMR, DataHub, and related platforms to identify care gaps
Identify recently discharged inpatient, observation, and emergency department patients and coordinate timely post-discharge follow-up
Conduct patient and provider outreach by phone, telehealth, and in-clinic visits
Provide education on preventive care, chronic disease management, and medication management
Conduct post-discharge outreach, medication reconciliation, symptom monitoring, and follow-up adherence checks
Identify and escalate barriers and collaborate with providers and care teams to prevent readmissions and avoidable ED utilization
Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff
Document outreach, clinical interactions, outcomes, and patient encounters accurately and in compliance with organizational and CMS standards
Participate in center huddles and high-risk rounds
Participate in quality improvement projects, provider education sessions, and team huddles
Monitor progress toward Stars and Transitional Care Management goals and develop solutions to improve performance and engagement
Support clinic operations through provider collaboration, care coordination, and community education
Coordinate and facilitate in-person Wellness Events for Stars care opportunity closures
Maintain patient confidentiality under HIPAA
Follow safety, infection control, attendance, and other organizational policies
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 in the State of Virginia
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 preferred
Experience with Transitions of Care, hospital discharge, or ER follow-up programs preferred
Strong clinical judgment and data analysis skills preferred
Ability to apply evidence-based practices preferred
Excellent communication and motivational interviewing skills preferred
Bilingual English and Spanish with full professional proficiency preferred
Basic Life Support trained preferred
Valid state driver's license
Personal vehicle liability insurance meeting applicable requirements

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
Professional growth opportunities