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Posted 17 days ago
Requirements and responsibilities
Job Title: RN -Clinical Care Nurse/Quality Improvement
Duration:3 plus month with possible extension
Location: Work From Home (Florida)
Pay Range: $34- $37.00/hr
Must Be Licensed RN in Florida
Shift: M-F 8a-5p (local time)
Duties and Responsibilities:
• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to 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 and telehealth 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
• proactively identify barriers, and contribute to developing innovative solutions to improve clinical performance and patient engagement.
• Maintain patient confidentiality in accordance with HIPAA
Required Qualifications:
• Minimum of 3 years clinical nursing experience with exposure to transitions of care,
quality improvement, managed care, or population health management.
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.
• Proficiency with electronic health records (e.g., Athena EMR), data analytics tools
(DataHub), and Microsoft Office Suite.
Optionally, you can add more information later (benefits, pre-screening questions, etc.)