Clinical Care Nurse, RN

• Improve patient outcomes through clinical quality and transitions-of-care support
• Coordinate follow-up for recently discharged inpatient, observation, and emergency department patients
• Prevent avoidable readmissions and emergency department return visits
• Analyze clinical data and trends in Athena EMR and Data Hub to identify Stars, HEDIS, and transition-of-care gaps
• Conduct patient and provider outreach by phone, telehealth, and in-clinic visits
• Provide education on preventive care, chronic disease management, medication management, and self-management
• Perform post-discharge assessment, medication reconciliation, symptom monitoring, and follow-up adherence checks
• Identify and elevate barriers in collaboration with providers and care teams
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows
• Document outreach, clinical interactions, patient encounters, and outcomes in compliance with organizational and CMS standards
• Participate in center huddles and high-risk rounds
• Participate in quality improvement projects, provider education sessions, and team huddles
• Monitor Stars and Transitional Care Management goals and develop solutions to improve performance and engagement
• Support clinic operations, care coordination, community education, and market-based wellness events
• Maintain patient confidentiality in accordance with HIPAA
• Follow safety, infection control, attendance, and organizational policies
• Perform other duties as assigned

• Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN)
• Active, unrestricted RN license in the State of Arizona
• Bilingual in English and Spanish with full professional proficiency
• 3+ years' 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
• Proficiency with data analytics tools such as Data Hub, Compass Rose, and Salesforce Health Cloud
• Proficiency with Microsoft Office Suite
• Willing and able to complete and maintain Basic Life Support training
• Must reside in the designated market area within reasonable commuting distance to assigned clinics
• Valid state driver's license
• Personal vehicle liability insurance meeting specified minimum limits
• Ability to work Monday–Friday, 8:00 AM–5:00 PM, with additional time as required

Demonstrates expertise in clinical quality improvement, care coordination, and patient education, with a strong focus on transitions of care and data analysis. Proficient in utilizing electronic health records and data analytics tools to enhance patient outcomes and support interdisciplinary collaboration.

• Clinical Nursing Experience
• Transitions Of Care
• Data Analytics Proficiency
• Bilingual In English And Spanish
• Active RN License In Arizona

• Clinical Quality Improvement
• Patient Education
• Medication Reconciliation
• Symptom Monitoring
• Data Analysis
• Care Coordination
• Chronic Disease Management
• Preventive Care
• Quality Improvement Projects
• Post-Discharge Assessment

• Collaboration
• Communication
• Problem-Solving
• Patient Outreach
• Interpersonal Skills

• Active RN License
• Basic Life Support Training

• Patient Outcomes
• Transitions Of Care
• HEDIS
• Stars
• CMS Standards
• HIPAA Compliance
• Managed Care
• Population Health Management

• Athena EMR
• Data Hub
• Salesforce Health Cloud
• Microsoft Office Suite