Bilingual Clinical Care Nurse (RN)

CenterWell•Dallas, TX

2d•$71,100 - $97,800•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. The nurse supports safe Transitions of Care (TOC), reduces avoidable emergency department utilization, and advances Medicare Advantage Stars and quality performance. The role combines direct patient education and outreach with data-driven quality improvement and supports patients across care transitions. It emphasizes integrity, respect, empathy, health equity, and patient satisfaction. The role supports TOC follow-up and readmission prevention; Medicare Advantage Stars, HEDIS, and other quality performance across a value-based population; and culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. Work is in-center five days per week at assigned clinic(s), with occasional quarterly travel to other clinics in the market. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required. The employee must live within reasonable commuting distance of assigned clinic(s).

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license, as applicable to the state.
Full professional proficiency in both English and Spanish.
At least 3 years of 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, data analytics tools such as DataHub, Compass Rose, or Salesforce HealthCloud, and Microsoft Office Suite.
Willingness and ability 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 and personal vehicle liability insurance meeting the stated requirements.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Experience with transitions of care, hospital discharge, or emergency room follow-up programs.
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.
Excellent communication and motivational interviewing skills for educating and empowering members.
Commitment to health equity, inclusiveness, and patient-centered care.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize gaps in Stars and HEDIS measures, transitions of care, and post-hospitalization needs.
Identify recently discharged inpatient, observation, and emergency department patients and coordinate timely post-discharge follow-up in accordance with TOC and Transitional Care Management requirements.
Conduct patient and provider outreach by phone, telehealth, and in-clinic visits to close care gaps and provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, reconcile medications, monitor symptoms, and support follow-up appointment adherence; identify and escalate barriers in collaboration with providers and the care team.
Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff to implement evidence-based interventions and optimize workflows.
Accurately document outreach, clinical interactions, outcomes, and patient encounters in the indicated platform and in compliance with organizational, CMS, and HIPAA requirements.
Prepare for, participate in, and discuss patients during center huddles and high-risk rounds with providers and interdisciplinary teams.
Participate in quality improvement projects, provider education sessions, and team huddles to stay current with clinical guidelines and organizational priorities.
Monitor progress toward Stars and Transitional Care Management goals, identify barriers, and help develop solutions to improve clinical performance and patient engagement.
Support clinic operations through provider collaboration, care coordination, and community education initiatives.
Coordinate and facilitate center- and market-based wellness events focused on in-person engagement and closing Stars care opportunities.
Follow organizational policies related to safety, infection control, and attendance; perform other duties as assigned.
Maintain a valid state driver's license and personal vehicle liability insurance in accordance with the stated requirements; complete required TB screening if selected.