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 9/28/2026full-timeColumbia • South Carolina • 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 care coordination. Proficient in data analysis and electronic health records, with a commitment to patient-centered care and health equity.

Highest-signal resume keywords

Active RN License in South CarolinaClinical Nursing Experience (3+ Years)Proficiency with Athena EMRData Analysis SkillsBilingual in English and Spanish

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 ManagementChronic Disease ManagementTransitions of CareQuality ImprovementPatient EducationSymptom MonitoringMedication ReconciliationPreventive Care

Soft Skills

Excellent CommunicationMotivational InterviewingCollaborationCommitment to Health EquityPatient-Centered Care

Tools & Technologies

Athena EMRDataHubCompass RoseSalesForce HealthCloudMicrosoft Office Suite

Certifications & Qualifications

Basic Life Support TrainingActive RN License

Industry Keywords

Medicare Advantage StarsHEDISCAHPSCMS Quality RequirementsPopulation 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 from Athena EMR and DataHub to identify care gaps related to Stars, HEDIS, Transitions of Care, and post-hospitalization needs
Identify recently discharged inpatient, observation, and emergency department patients
Coordinate timely post-discharge follow-up aligned with TOC and TCM requirements
Conduct targeted patient and provider outreach by phone, telehealth, and in-clinic visits
Provide education on preventive care, chronic disease management, and medication management
Assess discharge-instruction understanding, medication reconciliation, symptom monitoring, and follow-up adherence
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, patient encounters, and outcomes 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 focused on closing Stars care opportunities
Maintain patient confidentiality in accordance with HIPAA
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 in the State of South Carolina
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
Must reside in the designated market area within reasonable commuting distance of assigned clinics
Valid state driver's license
Personal vehicle liability insurance meeting applicable minimum limits
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, data analysis skills, and ability to apply evidence-based practices preferred
Bilingual English and Spanish with full professional proficiency preferred
Excellent communication and motivational interviewing skills preferred
Commitment to health equity, inclusiveness, and patient-centered care preferred
Basic Life Support trained preferred
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
Smart healthcare decision support
Professional growth opportunities