Clinical Care Nurse (RN)

CenterWell•Golden Hills, CA

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, supporting safe Transitions of Care (TOC), reducing avoidable emergency department utilization, and advancing Medicare Advantage Stars and quality performance. The role combines direct patient education and outreach with data-driven quality improvement efforts across value-based populations. It emphasizes culturally appropriate chronic disease education and patient activation, particularly for diabetes, hypertension, congestive heart failure, and COPD. The role is based in a clinic, with possible locations in Golden Hills and South Mountain, Arizona. It requires an in-center presence five days per week and daily commuting to assigned clinics, with occasional quarterly travel to other clinics in the market for strategic meetings. Candidates must reside within a reasonable commuting distance of their assigned clinic. Hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required. The position is patient-facing and subject to TB screening. It also requires a valid state driver's license and personal vehicle liability insurance meeting applicable requirements. The nurse works with patients, providers, and interdisciplinary clinic teams to identify care gaps, coordinate post-discharge follow-up, support medication management and chronic disease self-management, and prevent avoidable readmissions and return visits. The role includes accurate and timely documentation in designated systems, compliance with HIPAA and organizational and CMS standards, participation in quality improvement and team activities, and support for wellness events and clinic operations.

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.
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 applicable state minimums or the stated coverage requirements.
Ability to attend the assigned clinic(s) in person five days per week and travel occasionally within the market to alternative clinics.
Ability to work Monday through Friday, 8:00 a.m. to 5:00 p.m., with additional time as required.

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 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 proficiency at a full professional level.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize care gaps related to 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 using a bottles-out approach, monitor symptoms, and support adherence to follow-up appointments.
Identify and escalate barriers to care, 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.
Accurately document outreach, clinical interactions, encounters, and outcomes in designated platforms in compliance with organizational and CMS 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.
Maintain patient confidentiality in accordance with HIPAA.
Follow organizational safety, infection-control, and attendance policies.
Perform other duties as assigned.