Clinical Care Nurse — NC at CenterWell Senior Primary

About the Role

The Clinical Care Nurse (RN) serves as a vital bridge between hospital discharge and home care, focusing on improving patient outcomes and ensuring safe transitions of care. This role is designed to reduce avoidable emergency department utilization and drive performance in Medicare Advantage Stars ratings. By proactively identifying care opportunities and engaging both patients and providers, the Clinical Care RN contributes directly to the organization's mission of advancing clinical quality and health equity.

This position balances direct patient education and outreach with data-driven quality improvement efforts. You will work remotely from Kansas or Missouri, aligning daily responsibilities with core organizational values of integrity, respect, empathy, and a commitment to health equity. The role involves analyzing clinical data to close care gaps, conducting targeted outreach to prevent readmissions, and delivering culturally appropriate chronic disease education, particularly for Diabetes and Hypertension.

While the primary scope is remote, there is an opportunity for conversion to a full-time, in-center role based on team needs, performance evaluations, and the availability of vacancies near the candidate's location. This conversion is not guaranteed and depends on the candidate's fit and willingness to relocate to a facility.

Hiring Process & Requirements

To be considered for this position, candidates must be licensed Registered Nurses (RN) in either Kansas or Missouri. A full NURSYS report and proof of your active, unrestricted RN state license must be presented at the time of submittal. The role requires a Bachelor's degree in Nursing and a minimum of three years of clinical nursing experience, preferably with exposure to transitions of care, quality improvement, or population health management.

Successful candidates will demonstrate strong clinical judgment, proficiency with electronic health records (such as Athena EMR), and the ability to apply evidence-based practices. Bilingual proficiency in English and Spanish or Creole is preferred where market-dependent.

Equal Opportunity

We are committed to fostering a diverse and inclusive environment. We champion continuous learning, innovation, and professional growth while upholding our mission to improve health outcomes through proactive, compassionate care. All interactions are grounded in integrity, respect, and empathy.

Work location

Work model: Remote

Auman Road, Southern Acres, Wake County, North Carolina, 27603, United States

North Carolina

Key Responsibilities

check_circleConduct targeted patient and provider outreach via phone and telehealth to close care opportunities
check_circleAssess patient understanding of discharge instructions and perform medication reconciliation
check_circleCollaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows
check_circleDocument all outreach efforts, clinical interactions, and outcomes accurately in compliance with CMS standards
check_circleProvide culturally appropriate chronic disease education to activate patients in self-management
check_circleAnalyze clinical data from Athena EMR and DataHub to identify care gaps and prioritize high-impact opportunities
check_circleCoordinate timely post-discharge follow-up for inpatient, observation, and ED patients to prevent readmissions

Requirements

verifiedBachelor's degree in Nursing
verifiedActive, unrestricted RN license (state-specific as applicable)
verifiedMinimum of 3 years clinical nursing experience
verifiedFull NURSYS REPORT at time of Submittal
verifiedPresent RN State License at time of Submittal
verifiedLicensed RN in Kansas or Missouri

Nice to Have

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements. Experience with Transitions of Care, hospital discharge or ER follow up programs. Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (DataHub), and Microsoft Office Suite. 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, inclusivity, and patient-centered care. Bilingual in English and Spanish or Creole with full professional proficiency (market dependent).

Skills, education and keywords

Skills: RN, Nursys Report, Transitions Of Care, Medicare Advantage Stars, Hedis, Cahps, CMS, Athena Emr, Datahub, Microsoft Office Suite.

Education: Bachelor's degree in Nursing required.

Frequently asked questions about Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care

What does a Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care do?expand_more

Day-to-day, the Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care will conduct targeted patient and provider outreach via phone and telehealth to close care opportunities; assess patient understanding of discharge instructions and perform medication reconciliation; collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows; and document all outreach efforts, clinical interactions, and outcomes accurately in compliance with cms standards.

What are the requirements for this Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role?expand_more

To qualify for the Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care position, applicants should have: Bachelor's degree in Nursing; Active, unrestricted RN license (state-specific as applicable); Minimum of 3 years clinical nursing experience; Full NURSYS REPORT at time of Submittal; Present RN State License at time of Submittal; and Licensed RN in Kansas or Missouri.

Where is the Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role at CenterWell Senior Primary Care located?expand_more

Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care is based in Auman Road, Southern Acres, Wake County, North Carolina, 27603, United States. This is a remote role.

Is this Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement job remote, hybrid, or on-site?expand_more

CenterWell Senior Primary Care has listed this Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role as remote.

How much experience is required for this Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role?expand_more

Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care typically requires 3+ years of relevant experience at the mid level level.

What skills do you need for the Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role at CenterWell Senior Primary Care?expand_more

Key skills for Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care include RN; Nursys Report; Transitions Of Care; Medicare Advantage Stars; Hedis; Cahps; CMS; and Athena Emr.

What education is required for Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care?expand_more

Educational requirements for this role: Bachelor's degree in Nursing required.

What category does the Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement role belong to?expand_more

Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement at CenterWell Senior Primary Care is part of the healthcare & nursing job category on Recrutus.

Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement