Clinical Care Nurse (RN)

CenterWell•Peoria, AZ

7d•$71,100 - $97,800•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 supports patients across care transitions and helps advance clinical quality through proactive identification of care opportunities, patient and provider engagement, and evidence-based interventions. The role balances direct patient education and outreach with data-driven quality improvement, while reflecting organizational values of integrity, respect, empathy, and commitment to health equity. The role supports TOC follow-up and readmission prevention for patients discharged from inpatient, observation, and emergency department settings; Medicare Advantage Stars, HEDIS, and broader value-based population quality; and culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. The nurse collaborates with providers and interdisciplinary teams to address care gaps, coordinate follow-up, support chronic disease self-management, improve patient engagement, and optimize clinic workflows. The role is clinic-based and requires an in-center presence five days per week, with daily commuting to assigned clinics and occasional quarterly travel within the market to alternative clinics for strategic meetings. The employee must reside within the designated market area and a reasonable commuting distance of assigned clinics. Scheduled hours are Monday through Friday, 8:00 AM–5:00 PM; additional time may be required. This is a patient-facing role subject to Humana's TB screening program. A valid state driver's license and personal vehicle liability insurance meeting the stated minimum requirements are required.

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted registered nurse license in the State of Arizona.
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.
Valid state driver's license and personal vehicle liability insurance meeting the stated minimum requirements.
Must reside in the designated market area within reasonable commuting distance of assigned clinic(s).

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 and data analysis skills, with the 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 or English and Romanian.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends from 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 alignment with TOC and Transitional Care Management requirements.
Address root causes of utilization and support patients in preventing 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.
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, collaborating with providers and the care team to prevent readmissions and avoidable emergency department utilization.
Collaborate with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff, to implement evidence-based interventions and optimize workflows.
Document outreach efforts, clinical interactions, outcomes, and patient encounters accurately and promptly in the designated platform, in compliance with organizational, CMS, and HIPAA requirements.
Prepare for, participate in, and discuss patients during center huddles and high-risk rounds with providers and center-based 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 Stars care opportunity closures.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.