Bilingual Clinical Care Nurse (RN)

CenterWell•Dallas, TX

1d•Onsite

About The Position

The Bilingual Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes through safe transitions of care, reducing avoidable emergency department utilization, and advancing Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and uses evidence-based interventions while balancing direct patient education and outreach with data-driven quality improvement. The role supports patients following inpatient, observation, and emergency department discharges; promotes chronic disease self-management; and contributes to patient health outcomes and satisfaction in alignment with organizational values of integrity, respect, empathy, and health equity. The position is in-center five days per week at an assigned clinic in the designated market area, with daily commuting and occasional quarterly travel to alternative clinics for strategic meetings. Hours are Monday through Friday, 8:00 AM to 5:00 PM, and additional time may be required. The role is patient-facing and subject to Humana's TB screening program. It also requires a valid state driver's license and personal vehicle liability insurance meeting the applicable requirements.

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 clinic(s).
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 to educate and empower members.
Commitment to health equity, inclusiveness, and patient-centered care.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends using 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 post-discharge follow-up in alignment with TOC and TCM requirements.
Conduct targeted 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.
Assess patients' understanding of discharge instructions, reconcile medications, monitor symptoms, and support adherence to follow-up appointments.
Identify and escalate barriers, working with providers and the care team 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, and outcomes accurately and in accordance with organizational and CMS regulatory standards.
Prepare for and discuss patients in 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 Stars care opportunity closures.
Maintain patient confidentiality in accordance with HIPAA.
Follow organizational policies for safety, infection control, and attendance, and perform other duties as assigned.