Clinical Care Nurse (RN)

CenterWell•Belle Glade, FL

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. 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, and supports patients through care transitions and chronic disease self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position focuses on transitions of care, quality measures including Medicare Advantage Stars and HEDIS, and population health. It involves identifying care opportunities, coordinating timely post-discharge follow-up, engaging patients and providers, and delivering culturally appropriate, evidence-based interventions. The nurse collaborates with interdisciplinary clinic teams and contributes to quality improvement, patient engagement, and clinic operations. The role is clinic-based and requires in-center presence five days per week, Monday through Friday, 8:00 AM–5:00 PM. The employee must reside within a reasonable commute of assigned clinics in the designated market and may travel quarterly to alternative clinics for strategic meetings. The position is patient-facing and subject to TB screening. It also requires a valid state driver's license and personal vehicle liability insurance. Additional time may be required.

Requirements

Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN).
Active, unrestricted RN license in the State of Florida.
At least 3 years of clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
Full professional proficiency in both English and Spanish.
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 clinics.
Valid state driver's license and personal vehicle liability insurance meeting applicable minimum requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM; additional time may be required.
Must complete TB screening as part of the patient-facing role.

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 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 Transitional Care Management requirements.
Conduct targeted patient and provider outreach by phone, telehealth, and in-clinic visits to close care opportunities and provide tailored preventive care, chronic disease, and medication management education.
Conduct post-discharge outreach to assess understanding of discharge instructions, perform medication reconciliation, monitor symptoms, and support 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 accordance with organizational and CMS regulatory 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 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 policies related to safety, infection control, and attendance.
Perform other duties as assigned.