Clinical Care Nurse (RN)

CenterWell•Belle Glade, FL

3d•$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, reducing avoidable emergency department use, and advancing Medicare Advantage Stars, HEDIS, and other quality performance. The role combines direct patient education and outreach with data-driven quality improvement across a value-based population. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions. Responsibilities include coordinating follow-up for patients discharged from inpatient, observation, or emergency department settings; supporting medication reconciliation and symptom monitoring; and providing culturally appropriate education for chronic conditions, particularly diabetes, hypertension, congestive heart failure, and COPD. The position works closely with interdisciplinary clinic teams to close care gaps, prevent avoidable readmissions, and improve patient engagement and satisfaction. This is an in-center role, five days per week, at an assigned clinic in the designated market area, with occasional quarterly travel to alternative clinics for strategic meetings. The schedule is Monday through Friday, 8:00 AM to 5:00 PM; additional time may be required. The role is patient-facing and requires TB screening. It also requires a valid state driver's license and personal vehicle liability insurance.

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license, as applicable to the state.
At least 3 years of clinical nursing experience, with exposure to transitions of care, quality improvement, managed care, or population health management.
Full professional proficiency in both English and Spanish.
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.
Ability to work in-center five days per week, commute to assigned clinic(s), and reside within a reasonable commuting distance in the designated market area.
Valid state driver's license and ability to maintain personal vehicle liability insurance at the applicable required limits.
Ability to complete TB screening as part of the patient-facing role.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Experience with transitions of care, hospital discharge follow-up, or emergency room 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.
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 follow-up in alignment with Transitions of Care and Transitional Care Management requirements.
Conduct targeted outreach to patients and providers 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 use.
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, while complying with organizational and CMS requirements.
Prepare for and participate in center huddles and high-risk rounds with providers and interdisciplinary teams.
Participate in quality improvement projects, provider education sessions, and team huddles to stay current with clinical guidelines and organizational priorities.
Monitor Stars and Transitional Care Management goals, identify barriers, and help develop solutions to improve 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.