Analyze clinical data and trends from platforms such as Athena EMR and Data. Hub 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. Use your skills to make an impact Required Qualifications: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., Data. Hub, Compass Rose, SalesForce Health. Cloud – 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.