Clinical Care Nurse (RN)

CenterWell•Richardson, TX

5d•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based role focused on improving patient outcomes through safe transitions of care, reducing avoidable emergency department utilization, and supporting Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and applies evidence-based interventions while balancing direct patient education and outreach with data-driven quality improvement. The role supports patients after inpatient, observation, and emergency department discharges; contributes to HEDIS and Stars performance; and provides culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position is based in a clinic in the Dallas/DFW area (Richardson). It requires in-center work five days per week, a daily commute to assigned clinics, and occasional quarterly travel to alternative clinics within the market for strategic meetings. The schedule is Monday through Friday, 8:00 AM to 5:00 PM, with additional time potentially required. The nurse must reside within reasonable commuting distance of assigned clinics. This is a patient-facing role subject to TB screening and Humana’s driver safety program, including maintaining a valid state driver’s license and required personal vehicle liability insurance.

Requirements

Associate 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 meeting applicable minimum requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM, with additional time as required.
Ability to meet the requirements of the patient-facing role’s TB screening program.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Full professional proficiency in English and Spanish.
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 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 line with TOC and TCM requirements to 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.
Follow up after discharge to assess patients’ understanding of instructions, medication reconciliation, symptom monitoring, and adherence to follow-up appointments.
Identify and escalate barriers, collaborating with providers and the care team to prevent readmissions and avoidable emergency department use.
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, and outcomes accurately and in accordance with organizational and CMS requirements; maintain patient confidentiality under HIPAA.
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 closing Stars care opportunities.
Follow organizational policies related to safety, infection control, and attendance, and perform other duties as assigned.