Clinical Care Nurse (RN)

CenterWell•Biloxi, MS

3d•$64,000 - $88,000•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, reducing avoidable emergency department use, and supporting Medicare Advantage Stars and other quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions across transitions of care and population health. The role balances direct patient education and outreach with data-driven quality improvement, emphasizing integrity, respect, empathy, and health equity. The position supports care transitions and follow-up for patients discharged from inpatient, observation, and emergency department settings; quality performance across Medicare Advantage Stars, HEDIS, and value-based populations; and culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. The position is clinic-based, with five days per week in-center at an assigned clinic in Mississippi. Occasional quarterly travel to another clinic within the market is required. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required. The employee must live within reasonable commuting distance of the assigned clinic(s).

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license in the State of Mississippi.
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 maintenance of personal vehicle liability insurance meeting the stated minimum limits or the higher limits required by the employee's state.
Ability to work in-center five days per week and commute to assigned clinic(s) in the designated market area.

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 both English and Spanish.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize care gaps involving 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.
Address root causes of utilization and help patients 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 preventive care, chronic disease, and medication management education.
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, promptly, and in accordance with organizational and CMS requirements.
Prepare for and participate in 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 contribute 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.