Clinical Care Nurse (RN)

CenterWell•Middleburg, 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), 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 while balancing direct education and outreach with data-driven quality improvement. The role supports care transitions and follow-up for patients discharged from inpatient, observation, and emergency department settings; quality performance across Medicare Advantage Stars and HEDIS measures; and population health through culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position is based at a clinic in Middleburg, Florida, with in-center work five days per week and occasional quarterly travel to other clinics in the market. The nurse works with providers and interdisciplinary teams to coordinate care, address barriers, and improve patient engagement and health outcomes. The role requires accurate, timely documentation and compliance with HIPAA, CMS requirements, and organizational policies. The position is scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required.

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.
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 within the designated market area and a reasonable commuting distance from the assigned clinic.
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 and Spanish.
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, medication reconciliation, symptom monitoring, and 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 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 compliance with organizational and CMS standards.
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 closing Stars care opportunities.
Maintain patient confidentiality in accordance with HIPAA.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.