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

Center Well clinic locations may be available in the following areas: CW Hampton, CW SE Newport News.

• 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 population.
• Population Health:
  Deliver culturally appropriate chronic disease education to activate patients in chronic disease 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 gaps in care 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, ensuring root causes of utilization are addressed and preventing 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, medication reconciliation, symptom monitoring and follow‑up appointment adherence, identifying and escalating barriers, and collaborating with providers and the 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 in 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.
• Coordinate and facilitate center and market‑based Wellness Events focused on 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.

• 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., Data Hub, Compass Rose, Sales Force Health Cloud – 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.

• Knowledge of Medicare…