Clinical Care Nurse (RN)

CenterWell•Hallandale Beach, FL

3d•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes by supporting safe transitions of care, reducing avoidable emergency department utilization, and driving 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 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 education for chronic disease self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position is based in a clinic in Hallandale, Florida, with in-center work five days per week and occasional quarterly travel to other clinics in the market. The schedule is Monday through Friday, 8:00 AM to 5:00 PM, with additional time potentially required. The position requires an active, unrestricted Florida RN license, an associate's or bachelor's degree in nursing, at least three years of clinical nursing experience, professional English and Spanish proficiency, and the ability to complete and maintain Basic Life Support training. 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.
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.
Full professional proficiency in English and Spanish.
Willingness and ability to complete and maintain Basic Life Support training.
Must reside in the designated market area within reasonable commuting distance of assigned clinics.
Valid state driver's license and personal vehicle liability insurance meeting applicable requirements.
Must complete TB screening for this patient-facing role.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Experience with transitions of care, hospital discharge follow-up, 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 and HEDIS measures, 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 transitions of care 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.
Accurately document outreach, clinical interactions, outcomes, and patient encounters in the designated platform in compliance with organizational, HIPAA, and CMS requirements.
Prepare for and participate in center huddles and high-risk patient 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.
Follow organizational policies related to safety, infection control, and attendance, and perform other duties as assigned.