Clinical Care Nurse (RN)

CenterWell•Belle Glade, FL

3d•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), reduced avoidable emergency department utilization, and stronger Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and supports evidence-based interventions across a value-based population. The role balances patient education and outreach with data-driven quality improvement, while supporting health equity and compassionate, patient-centered care. The position supports care transitions and follow-up for patients discharged from inpatient, observation, and emergency department settings; Medicare Advantage Stars, HEDIS, and other quality performance; and culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. Duties also include post-discharge assessment, medication reconciliation, care coordination, accurate documentation, participation in center huddles and high-risk rounds, quality improvement work, and community wellness events. This is an in-center role, five days per week, with daily commuting to assigned clinic locations and occasional quarterly travel to alternative clinics within the market for strategic meetings. The role is based in the Belle Glade or Everglades Conviva clinic areas, and the employee must live within a reasonable commuting distance of the assigned clinic. Regular hours are Monday through Friday, 8:00 AM to 5:00 PM; additional time may be required. The role is patient-facing and requires TB screening, a valid state driver's license, and personal vehicle liability insurance.

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.
Bilingual in English and Spanish with full professional proficiency.
Proficiency with electronic health records such as Athena EMR, data analytics and population health 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).
Must have a valid state driver's license and maintain personal vehicle liability insurance meeting the stated requirements.
Must complete TB screening as part of Humana's patient-facing employee screening program.

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 for educating and empowering 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 accordance 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 education on preventive care, chronic disease management, and medication management.
Assess patients' understanding of discharge instructions, reconcile medications, monitor symptoms, and support adherence to follow-up appointments.
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.
Document outreach, clinical interactions, patient encounters, and outcomes accurately and in accordance with organizational, HIPAA, and CMS 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 remain current on 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.
Follow organizational safety, infection control, and attendance policies, and perform other duties as assigned.