Clinical Care Nurse (RN

Become a part of our caring community

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. The RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve outcomes.

Center

Location:

West Pembroke Pines, Florida.

• Transitions:
  Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients.
• Quality:
  Medicare Advantage Stars, HEDIS and quality performance across value-based populations.
• Population Health:
  Deliver culturally appropriate chronic disease education to activate patients in self‑management, particularly in DM, HTN, CHF and COPD.

• Analyze clinical data and trends from platforms such as Athena EMR and Data Hub to identify care gaps related to Stars and HEDIS measures, 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.
• 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, medication reconciliation, symptom monitoring and follow‑up appointment adherence; identify and escalated barriers in collaboration with providers to 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.
• Document all outreach efforts, clinical interactions and outcomes accurately and in compliance with organizational and CMS regulatory standards.
• Participate in patient huddles and high‑risk rounds with providers and the interdisciplinary team.
• Participate in quality improvement projects and provider education sessions to stay current with evolving clinical guidelines and organizational priorities.
• Monitor progress toward Stars and TCM 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.
• Coordinate and facilitate a center‑based wellness event focused on Stars care opportunity closures.
• Maintain patient confidentiality in accordance with HIPAA.
• Follow organizational policies related to safety, infection control and attendance.
• Perform other duties as assigned.

• 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 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., Data Hub, Compass Rose, Sales Force Health Cloud) and Microsoft Office Suite.
• Bilingual in English and Spanish with full professional proficiency.
• Willing and able to complete and maintain Basic Life Support training.

• 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 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.
• Basic Life Support trained.

• Core Competencies:
  
  Clinical…