Clinical Care Nurse (RN)

CenterWell

1d•$71,100 - $97,800•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes through safe Transitions of Care (TOC), reduced avoidable emergency department utilization, and improved Medicare Advantage Stars and quality performance. The role identifies care opportunities, engages patients and providers, and delivers evidence-based interventions through direct education and outreach and data-driven quality improvement. The nurse supports recently discharged inpatient, observation, and emergency department patients with follow-up coordination and readmission prevention. The role also provides culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD, and supports Medicare Advantage Stars, HEDIS, and other quality goals across a value-based population. The position is clinic-based, with an in-center presence five days per week. The nurse must reside within a reasonable commuting distance of assigned clinics in the designated market and may travel quarterly to alternative clinics within the market. Hours are Monday through Friday, 8:00 AM–5:00 PM; additional time may be required. The position is patient-facing and requires TB screening. It also requires a valid state driver's license and maintenance of personal vehicle liability insurance.

Requirements

Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN).
Active, unrestricted RN license in the State of Georgia.
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 Health Cloud, 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 department follow-up programs.
Strong clinical judgment and data analysis skills, with the 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.
Full professional proficiency in English and Spanish.
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, 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 line with TOC and Transitional Care Management requirements.
Conduct targeted patient and provider outreach by phone, telehealth, and in-clinic visits to close care opportunities and provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, medication reconciliation, symptom monitoring, and follow-up appointment adherence.
Identify and escalate barriers, collaborating 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.
Accurately document outreach, clinical interactions, and outcomes in the indicated platform and in compliance with organizational and CMS standards.
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 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 closure of Stars care opportunities.
Maintain patient confidentiality in accordance with HIPAA.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.