Clinical Care Nurse (RN)

About the role

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. You will support safe Transitions of Care (TOC), reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance.

Responsibilities

• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.
• Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits.
• Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.
• Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization.
• Collaborate effectively 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 all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
• Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.
• Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.
• Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
• Support clinic operations through provider collaboration, care coordination, and community education initiatives.
• Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.
• Maintain patient confidentiality in accordance with HIPAA.
• Document patient encounters accurately and timely in the indicated platform (e.g., medical record).
• Follow organizational policies related to safety, infection control, and attendance.
• Perform other duties as assigned.

  Requirements

  • Must meet one of the following requirements: Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN).
  • Active, unrestricted RN license (state specific as applicable).
  • 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
  • Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer's population health tools), and Microsoft Office Suite.
  • Proficient in both Spanish and English.
  • Willing and able to complete and maintain Basic Life Support training.

  Preferred Qualifications

  • Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
  • Experience with Transitions of Care, hospital discharge or ER 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.

  Additional Information

  • Core Competencies: Clinical quality improvement and strategic gap closure.
  • Transitions of Care coordination and post-discharge support.
  • Member and provider engagement with motivational interviewing.
  • Regulatory compliance and documentation accuracy.
  • Data interpretation and actionable reporting.
  • Cross-functional collaboration and teamwork.
  • Time management balancing administrative and outreach duties.

  Values & Mission Alignment

  • Demonstrate integrity, respect, and empathy in all interactions.
  • Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.
  • Champion continuous learning, innovation, and professional growth.