Clinical Care Nurse (RN)

CenterWell•Richardson, TX

1d•$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, 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 for a value-based population, while promoting integrity, respect, empathy, and health equity. The role supports discharged inpatient, observation, and emergency department patients through care-transition follow-up, coordination, and readmission prevention. It also identifies and closes Stars and HEDIS care gaps and provides culturally appropriate education to support chronic disease self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position is in-center five days per week at an assigned clinic in the Dallas/DFW area, specifically Richardson. The employee must live within a reasonable commuting distance of assigned clinics and may travel quarterly to alternative clinics within the market for strategic meetings. Hours are Monday through Friday, 8:00 AM–5:00 PM; additional time may be required. The role is patient-facing and requires 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 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 clinic(s).
Valid state driver's license and personal vehicle liability insurance meeting the stated minimum coverage requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM, with additional time potentially required.
Must complete TB screening if selected for the 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 using 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 line with TOC and TCM requirements to address utilization drivers and help prevent readmissions or 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, perform medication reconciliation, monitor symptoms, and support 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 required platform and in compliance with organizational, CMS, and HIPAA requirements.
Prepare for and participate in center huddles and high-risk rounds with providers and interdisciplinary teams to discuss patients.
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.
Perform other duties as assigned.