Clinical Care Nurse (RN)

CenterWell•Peoria, AZ

6d•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 advancing 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 care transitions and post-discharge follow-up for inpatient, observation, and emergency department patients; contributes to Medicare Advantage Stars, HEDIS, and other quality measures; and provides culturally appropriate chronic disease education and self-management support, particularly for diabetes, hypertension, congestive heart failure, and COPD. Work includes outreach by phone, telehealth, and in-clinic visits, coordination with interdisciplinary teams, and accurate documentation in accordance with organizational and CMS requirements. The position is clinic-based, in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM, with additional time potentially required. It requires daily commuting to assigned clinics and occasional quarterly travel to other clinics within the market. The nurse must reside within reasonable commuting distance of the assigned clinic(s). The role is patient-facing and subject to Humana’s TB screening program. A valid state driver’s license and personal vehicle liability insurance meeting the stated requirements are required.

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.
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 the stated 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, 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.
Full professional proficiency in English/Spanish or English/Romanian.
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, 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 outreach to patients and providers by phone, telehealth, and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, perform medication reconciliation, assess symptom monitoring, 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 interdisciplinary teams—including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows.
Document outreach, clinical interactions, patient encounters, and outcomes accurately and in a timely manner, in compliance with organizational, CMS, and HIPAA requirements.
Prepare for and participate in center huddles and high-risk rounds with providers and center-based 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 Stars care opportunity closures.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.