Clinical Care Nurse (RN)

CenterWell•Clermont, FL

5d•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. The nurse supports safe Transitions of Care (TOC), reduces avoidable emergency department utilization, and advances Medicare Advantage Stars and quality performance. The role contributes to clinical quality by identifying care opportunities, engaging patients and providers, and delivering evidence-based interventions. It balances direct patient education and outreach with data-driven quality improvement, while supporting health equity and patient satisfaction. The role supports care transitions, follow-up coordination, and prevention of avoidable readmissions for patients discharged from inpatient, observation, and emergency department settings. It also advances Medicare Advantage Stars, HEDIS, and other quality performance across a value-based population, and delivers culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position requires an in-center presence five days per week at assigned clinic(s), with a daily commute and occasional quarterly travel to other clinics within the market for strategic meetings. The employee must reside within reasonable commuting distance of the designated market area. Hours are Monday through Friday, 8:00 AM–5:00 PM; additional time may be required. The position is patient-facing and subject to Humana's TB screening program. It also participates in the driver safety program and 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 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 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).
Valid state driver's license and personal vehicle liability insurance that meets applicable state minimum limits or the stated coverage thresholds, whichever is higher.

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 English and Spanish proficiency at a full professional level.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends in 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.
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 medication management.
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 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, clinical interactions, outcomes, and patient encounters accurately and in a timely manner in the appropriate platform, in compliance with organizational and CMS standards.
Prepare for, participate in, and discuss patients during center huddles and high-risk rounds with providers and the center-based interdisciplinary team.
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.