Bilingual Clinical Care Nurse (RN)

CenterWell•Orlando, FL

18h•$71,100 - $97,800•Onsite

About The Position

The Bilingual Clinical Care Nurse (RN) is a clinic-based role focused on improving patient outcomes through safe transitions of care, reduced avoidable emergency department utilization, and stronger Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions across transitions of care and chronic disease management. The role combines direct patient education and outreach with data-driven quality improvement, while advancing health equity and patient satisfaction. The role supports recently discharged inpatient, observation, and emergency department patients through timely follow-up, care coordination, medication reconciliation, and readmission prevention. It also supports Medicare Advantage Stars, HEDIS, and other quality goals through clinical data analysis, patient and provider engagement, documentation, and collaboration with interdisciplinary teams. This is an in-center role, five days per week, based at the assigned clinic in Orlando, Florida. The schedule is Monday through Friday, 8:00 AM to 5:00 PM, with additional time possibly required. The position requires daily commuting to assigned clinic(s), occasional quarterly travel to other clinics in the market, residence within a reasonable commuting distance, a valid state driver's license, and personal vehicle liability insurance. The role is patient-facing and requires TB screening.

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license, as applicable to the state.
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.
Full professional proficiency in both English and Spanish.
Willingness and ability to complete and maintain Basic Life Support training.
Must reside in the designated market area within a reasonable commuting distance of assigned clinic(s).
Valid state driver's license and personal vehicle liability insurance meeting applicable 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 to educate and empower members.
Commitment to health equity, inclusiveness, and patient-centered care.
Basic Life Support training.

Responsibilities

Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize gaps in Stars, HEDIS, transitions of care, and post-hospitalization needs.
Identify recently discharged inpatient, observation, and emergency department patients and coordinate timely follow-up in alignment with Transitions of Care and Transitional Care Management requirements.
Conduct patient and provider outreach by phone, telehealth, and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, perform medication reconciliation, review symptom monitoring, and support follow-up appointment adherence.
Identify and escalate barriers, collaborating with providers and care teams to prevent readmissions and avoidable emergency department utilization.
Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff to implement evidence-based interventions and optimize workflows.
Document outreach, clinical interactions, outcomes, and patient encounters accurately, timely, 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.
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.