Clinical Care Nurse (RN)

CenterWell•Chesapeake, VA

4d•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), reducing avoidable emergency department utilization, and supporting Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions through a combination of direct education and outreach and data-driven quality improvement. The role supports recently discharged inpatient, observation, and emergency department patients with follow-up coordination and readmission prevention. It also contributes to HEDIS and other quality measures, and provides culturally appropriate chronic disease education to encourage self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. The nurse works with interdisciplinary clinic and market teams, maintains accurate and compliant documentation, and aligns daily work with organizational values of integrity, respect, empathy, and health equity. This is an in-center role, five days per week, with a daily commute to assigned clinic locations and occasional quarterly travel to alternative clinics within the market. The position is based in the designated market area, with listed Virginia locations including CW Hampton, CW SE NewportNews, and Chesapeake. Hours are Monday through Friday, 8:00 AM–5:00 PM; additional time may be 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 meeting the stated requirements.

Requirements

Associate degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted registered nurse license in the State of Virginia.
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 applicable stated minimum requirements.
Ability to travel occasionally within the market to alternative clinic locations for strategic meetings.

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 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 accordance with TOC and TCM requirements.
Conduct 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.
Follow up after discharge to assess understanding of discharge instructions, perform medication reconciliation, monitor symptoms, and support adherence to follow-up appointments.
Identify and escalate barriers and collaborate 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.
Document outreach, clinical interactions, outcomes, and patient encounters accurately, promptly, 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 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.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.