Clinical Care Nurse (RN)

CenterWell•Grand Prairie, TX

3d•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), reducing avoidable emergency department utilization, and improving Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions, balancing direct patient education and outreach with data-driven quality improvement. The role supports recently discharged inpatient, observation, and emergency department patients through timely follow-up, care coordination, and readmission prevention. It also provides culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD, and supports preventive care, medication management, and patient self-management. The position works closely with providers and interdisciplinary clinic teams and contributes to quality improvement, center operations, and community education. This is an in-center position, five days per week, Monday through Friday, 8:00 AM to 5:00 PM, with additional time potentially required. The nurse must reside within a reasonable commuting distance of the assigned clinic in the designated market area. Clinic locations are in Dallas–Grand Prairie and Redbird, with occasional quarterly travel to other clinics in the market for strategic meetings. 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 in the State of Texas.
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 stated minimum requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 AM to 5:00 PM; additional time may be required.
Ability to complete required TB screening for this patient-facing role.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Full professional proficiency in both English and Spanish.
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.
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, 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 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 medication management.
Conduct post-discharge outreach to assess patients’ understanding of discharge instructions, complete medication reconciliation, monitor symptoms, and support follow-up appointment adherence.
Identify and escalate barriers, collaborating with providers and care teams 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, patient encounters, and outcomes accurately and in a timely manner, complying with organizational, HIPAA, and CMS standards.
Prepare for, participate in, and discuss patients during 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 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, and perform other duties as assigned.