Clinical Care Nurse (RN)

CenterWell•Middleburg, FL

4d•$71,100 - $97,800•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes by supporting safe transitions of care, reducing avoidable emergency department utilization, and advancing Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and applies evidence-based interventions while balancing direct patient education and outreach with data-driven quality improvement. The role supports discharged inpatient, observation, and emergency department patients through transition follow-up and coordination, and contributes to Medicare Advantage Stars, HEDIS, and other quality goals across a value-based population. It also provides culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD, to encourage patient engagement in self-management. The position is based in a clinic in Middleburg, Florida, with in-center work five days per week. The employee must live within a reasonable commuting distance of assigned clinic locations and may travel quarterly to other clinics in the market for strategic meetings. The schedule is Monday through Friday, 8:00 AM to 5:00 PM, with additional time potentially required. This is a patient-facing role requiring TB screening, 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 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 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 and commute to assigned clinic locations.
Must reside in the designated market area within reasonable commuting distance of assigned clinics.
Valid state driver's license and personal vehicle liability insurance meeting applicable requirements.
Ability to complete required tuberculosis screening.

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 English and Spanish.
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 alignment with TOC and TCM 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 preventive care, chronic disease, and medication management education.
Conduct post-discharge outreach to assess understanding of discharge instructions, perform medication reconciliation, monitor symptoms, and support adherence to follow-up appointments.
Identify and escalate barriers and collaborate with providers and the care team to help prevent readmissions and avoidable ED 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.
Accurately document outreach, clinical interactions, patient encounters, and outcomes in the appropriate platform and in accordance with organizational and CMS requirements.
Prepare for and participate in center huddles and high-risk patient rounds with providers and interdisciplinary teams.
Participate in quality improvement projects, provider education sessions, and team huddles to remain current with clinical guidelines and organizational priorities.
Monitor progress toward Stars and TCM 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 safety, infection control, and attendance policies.
Perform other duties as assigned.