Clinical Care Nurse (RN)

OverviewThe Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes, supporting safe Transitions of Care (TOC), reducing avoidable emergency department utilization, and driving quality performance across Medicare Advantage populations.This role blends direct patient outreach and education with data-driven quality improvement initiatives. The Clinical Care RN works collaboratively with interdisciplinary teams to identify care gaps, support patients through transitions, and implement evidence-based interventions that improve outcomes, satisfaction, and health equity.ResponsibilitiesSupport Transitions of Care by identifying recently discharged inpatient, observation, and emergency department patients and coordinating timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements.Analyze clinical data and trends using electronic health records and reporting platforms to identify gaps in care related to HEDIS measures, post-hospitalization needs, and quality performance.Conduct proactive patient and provider outreach via phone and telehealth to close care gaps and provide education on preventive care, chronic disease management, and medication adherence.Perform post-discharge outreach to assess understanding of discharge instructions, complete medication reconciliation, monitor symptoms, and confirm follow-up appointment adherence.Identify and escalate barriers to care, collaborating with providers and care teams to prevent avoidable readmissions and emergency department utilization.Deliver culturally appropriate education to support chronic disease self-management, with a focus on conditions such as diabetes and hypertension.Collaborate with interdisciplinary teams, including providers, care assistants, medical assistants, pharmacy, quality, and administrative staff, to optimize workflows and implement evidence-based interventions.Accurately document all outreach efforts, clinical interactions, and outcomes in compliance with organizational policies and CMS regulatory standards.Maintain patient confidentiality in accordance with HIPAA.Follow organizational policies related to safety, infection control, and attendance.Perform other duties as assigned.Required QualificationsBachelor s degree in Nursing.Active, unrestricted Registered Nurse (RN) license (state-specific, as applicable).Minimum of 3 years of clinical nursing experience, with exposure to transitions of care, quality improvement, managed care, or population health.Strong clinical judgment and ability to apply evidence-based practices.Excellent communication skills, including the ability to educate and engage patients effectively.Proficiency with electronic health records and standard productivity tools.Preferred QualificationsKnowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.Experience with Transitions of Care, hospital discharge planning, or emergency department follow-up programs.Experience using data and analytics tools to drive quality improvement.Motivational interviewing skills and experience engaging diverse patient populations.Commitment to health equity, inclusivity, and patient-centered care.Bilingual proficiency in English and Spanish or Creole (market dependent). All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, identity, national origin, disability, or protected veteran status.