Clinical Care Nurse (RN)

CenterWell•Surprise, AZ

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. 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 efforts, supporting patients through transitions of care and promoting health equity, integrity, respect, and empathy. The role covers transitions of care, including follow-up coordination and readmission prevention for patients discharged from inpatient, observation, and emergency department settings; quality performance across Medicare Advantage Stars and HEDIS measures; and population health, including culturally appropriate chronic disease education, especially for diabetes, hypertension, congestive heart failure, and COPD. The position is based in a clinic in Surprise, Arizona, with in-center work five days per week. The nurse must live within a reasonable commute of the assigned clinic and may travel quarterly to other clinics in the market for strategic meetings. Hours are Monday through Friday, 8:00 AM–5:00 PM, with additional time potentially required. The role is patient-facing and subject to TB screening. It also requires a valid state driver's license and 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 Arizona.
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.
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 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.
Bilingual English and Spanish skills at full professional proficiency.
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 alignment with TOC and TCM requirements to address utilization risks and help prevent avoidable readmissions and return visits.
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, perform medication reconciliation, monitor symptoms, and support follow-up appointment adherence; identify barriers and collaborate with providers and the care team to prevent readmissions and avoidable ED 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, outcomes, and patient encounters in the designated platform in accordance 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 TCM 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 concerning safety, infection control, and attendance.
Perform other duties as assigned.