Clinical Care Nurse (RN)

CenterWell•Clermont, FL

6d•$71,100 - $97,800•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 other quality performance. The role combines direct patient education and outreach with data-driven quality improvement, with a focus on patient health outcomes, satisfaction, health equity, and organizational values of integrity, respect, and empathy. The role supports care transitions and follow-up for patients discharged from inpatient, observation, and emergency department settings; quality performance across value-based populations; and culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease. The position is clinic-based, with an in-center presence five days per week at assigned clinic locations in the designated market. The listed location is Clermont, Florida. The schedule is Monday through Friday, 8:00 AM–5:00 PM, with additional time potentially required. Occasional quarterly travel to alternative clinics within the market is required. The role is patient-facing and subject to TB screening, and requires a valid state driver's license and personal vehicle liability insurance.

Requirements

Associate 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 meeting applicable state minimum limits or the stated coverage amounts, 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 room 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 with full professional proficiency.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends using 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 TOC and Transitional Care Management requirements to help prevent 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, medication reconciliation, symptom monitoring, and follow-up appointment adherence; identify and escalate barriers and collaborate with providers and the care team to prevent readmissions and avoidable ED 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, patient encounters, and outcomes accurately and promptly in the appropriate platform and 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 closing Stars care opportunities.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.