Clinical Care Registered Nurse (RN)
CenterWell Senior Primary Care · Dallas, TX
- On site
- Full-time
- $84,000 / year
- Dallas, TX
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Clinical Care Registered Nurse (RN)
CenterWell Senior Primary Care · Dallas, TX
Sam Bennett
Hiring Manager · h•••••@click.appcast.io
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Subject: Interested in the Clinical Care Registered Nurse (RN) role at CenterWell Senior Primary Care
Hi Sam — I came across the Clinical Care Registered Nurse (RN) opening and wanted to reach out directly. I've spent the last few years doing exactly this kind of work, and CenterWell Senior Primary Care stood out because…
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Job highlights
- Improve patient outcomes via care transitions.
- Reduce avoidable ER visits and readmissions.
- Drive Medicare Advantage Stars quality performance.
- Educate patients on chronic disease management.
- Collaborate with interdisciplinary care teams.
About the role
About the Role
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: CenterWell Northwest Dallas
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 in 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 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.
Required Qualifications
Use your skills to make an impact
- Must meet one of the following requirements: 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 – per your prior employer's population health tools), and Microsoft Office Suite.
- Willing and able to complete and maintain Basic Life Support training.
Preferred Qualifications
- 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, data analysis skills, and ability to apply evidence-based practices.
- Excellent communication and motivational interviewing skills to educate and empower members.
- Commitment to health equity, inclusiveness, and patient-centered care.
- Bilingual in English and Spanish with full professional proficiency (strongly preferred).
- Basic Life Support trained.
Key Skills/Competency
- Clinical Quality Improvement
- Transitions of Care
- Population Health Management
- Medicare Advantage Stars
- Registered Nurse
- Patient Education
- Electronic Health Records
- Data Analysis
- Chronic Disease Management
- Care Coordination
Skills & topics
- Clinical Care Registered Nurse
- RN
- Transitions of Care
- Quality Improvement
- Population Health Management
- Medicare Advantage Stars
- Patient Education
- Care Coordination
- Chronic Disease Management
- Registered Nurse
How to get hired
- Tailor your resume: Highlight experience in transitions of care, quality improvement, and population health management, using keywords from the job description like 'Medicare Advantage Stars' and 'TOC'.
- Showcase your skills: Emphasize proficiency with EHR systems (Athena EMR) and data analytics tools, as well as your RN license and years of experience.
- Prepare for behavioral questions: Be ready to discuss your experience with patient education, motivational interviewing, and collaborating with interdisciplinary teams.
- Demonstrate cultural fit: Research CenterWell's values of integrity, respect, empathy, and health equity, and be prepared to share examples of how you embody these principles.
- Network internally: If possible, connect with current CenterWell employees on LinkedIn to gain insights into the company culture and application process.
Technical preparation
Master Athena EMR and DataHub analytics.,Practice motivational interviewing techniques.,Review HEDIS and Stars quality measures.,Prepare case studies on patient transitions.
Behavioral questions
Describe a time you improved patient outcomes.,How do you handle difficult patient education?,How do you collaborate with diverse teams?,Share an experience preventing readmissions.
Prefer to apply the usual way?
Not recommended alone — most applicants never hear back. Email the hiring manager first.
Frequently asked questions
- What are the key responsibilities for a Clinical Care Registered Nurse at CenterWell Senior Primary Care?
- The Clinical Care Registered Nurse at CenterWell Senior Primary Care is responsible for improving patient outcomes through safe Transitions of Care (TOC), reducing avoidable Emergency Department (ED) utilization, and driving Medicare Advantage Stars and quality performance. This includes analyzing clinical data, coordinating post-discharge follow-up, providing patient and provider outreach, and collaborating with interdisciplinary teams.
- What qualifications are required for the Clinical Care RN position at CenterWell?
- To qualify for the Clinical Care RN role at CenterWell, you need an Associate's or Bachelor's degree in nursing (ADN or BSN), an active, unrestricted RN license, and at least 3 years of clinical nursing experience. Proficiency with electronic health records (like Athena EMR), data analytics tools, and the Microsoft Office Suite is also required, along with willingness to complete Basic Life Support training.
- What is the work arrangement for the Clinical Care RN at CenterWell Senior Primary Care?
- This Clinical Care Registered Nurse position is clinic-based and requires an in-center presence five days a week. While primarily assigned to one clinic, occasional travel to alternative clinics within the market for strategic meetings may be required. The role involves a standard Monday-Friday, 8:00 AM to 5:00 PM schedule, with potential for additional hours.
- How does CenterWell Senior Primary Care focus on patient care and quality?
- CenterWell Senior Primary Care emphasizes proactive, preventive care with a unique model that allows for more time with patients (up to 50% more). They focus on personalized experiences, addressing the factors that impact patient well-being beyond physical health, and integrating care teams including physicians, nurses, and behavioral health specialists to achieve better health outcomes and patient satisfaction.
- What kind of data and tools will a Clinical Care RN use at CenterWell?
- A Clinical Care RN at CenterWell will utilize clinical data and trends from platforms such as Athena EMR and DataHub. They will also work with other data analytics tools like Compass Rose and SalesForce HealthCloud, and the Microsoft Office Suite, to identify care gaps, coordinate patient care, and track outcomes.
- What is the compensation and benefits package for the Clinical Care RN role?
- The Clinical Care RN role offers a competitive annual salary range of $71,100 - $97,800, with eligibility for a bonus incentive plan based on company and individual performance. CenterWell, a Humana company, also provides a comprehensive benefits package including medical, dental, vision, 401(k) retirement savings, paid time off, disability insurance, and life insurance.