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.
• Covered under this section are duties such as conducting targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, providing 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.

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.
• Willing and able to complete and maintain Basic Life Support training.

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.

Skills

• Basic Life Support trained.

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Paid time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.
• Many other opportunities.

Pay

$71,100 - $97,800 per year

Schedule

Clinic-based, in-center 5 days per week.