Clinical Care Nurse (RN)

CenterWell•Mesa, AZ

19h•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 applies evidence-based interventions while balancing patient education and outreach with data-driven quality improvement. The role supports patients across care transitions and promotes culturally appropriate chronic disease self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. Clinic locations may be available in Golden Hills and South Mountain, Arizona. The position is in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM, with additional time potentially required. It involves commuting to assigned clinic(s) and occasional quarterly travel within the market to alternative clinics for strategic meetings. The employee must reside within reasonable commuting distance of the assigned clinic(s). This is a patient-facing role subject to Humana's TB screening program. The role also requires a valid state driver's license and personal vehicle liability insurance meeting applicable minimum limits.

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license, state-specific as applicable.
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 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 applicable state minimum or stated coverage limits.
Ability to work in-center five days per week and travel occasionally within the market to alternative clinics.

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.
Bilingual in English and Spanish with full professional proficiency.
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 alignment 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 education on preventive care, chronic disease management, and medications.
Conduct post-discharge outreach to assess 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, outcomes, and patient encounters accurately and promptly in the appropriate platform, complying with organizational, HIPAA, and CMS requirements.
Prepare for and participate in center huddles and high-risk rounds, discussing patients 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 closure of Stars care opportunities.
Follow organizational safety, infection control, and attendance policies, and perform other duties as assigned.