Clinical Care Nurse (RN)

CenterWell•Grand Prairie, TX

4d•$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, reduced avoidable emergency department utilization, and improved Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions while balancing direct patient education and outreach with data-driven quality improvement. The role supports patients across transitions of care and chronic disease self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD, using culturally appropriate education and a patient-centered approach. The role includes transitions-of-care support, follow-up coordination, and avoidable readmission prevention for patients discharged from inpatient, observation, and emergency department settings; quality improvement across Medicare Advantage Stars, HEDIS, and other value-based population measures; and population health education. The nurse works with interdisciplinary clinic teams, participates in patient huddles and high-risk rounds, documents care in accordance with organizational and CMS standards, and supports clinic operations and wellness events. The position is clinic-based, in-center five days per week, at assigned clinics in the Dallas–Grand Prairie or Redbird areas. The employee must live within a reasonable commuting distance of the assigned clinic and travel occasionally within the market for strategic meetings. 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 the stated requirements.

Requirements

Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN).
Active, unrestricted RN license in the State of Texas.
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 clinic(s).
Must have a valid state driver's license and maintain personal vehicle liability insurance at the required limits.
Ability to work in-center at an assigned clinic five days per week, Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required.
Must complete TB screening if selected for this patient-facing role.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Bilingual English and Spanish proficiency at a full professional level.
Experience with transitions-of-care, hospital discharge, or emergency department 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 in systems 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 consistent with TOC and TCM requirements to address utilization drivers 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, medication reconciliation, symptom monitoring, and follow-up appointment adherence; identify and escalate barriers in collaboration with providers and the care team.
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 appropriate platform 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 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 Stars care opportunity closures.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.