Role Overview
This Clinical Care Nurse position operates within a clinic setting to enhance patient outcomes by supporting care transitions, managing chronic conditions, and advancing quality performance. The nurse helps reduce unnecessary emergency department visits and hospital readmissions while contributing to key healthcare quality benchmarks, including Medicare Advantage Stars and HEDIS.
Key Responsibilities
- Review clinical data from electronic health records and analytics platforms to detect gaps in care, particularly related to quality measures, transitions of care, and post-hospitalization needs.
- Identify patients recently discharged from inpatient, observation, or emergency settings and coordinate timely follow-up care in accordance with Transitional Care Management protocols.
- Engage patients and providers through phone calls, telehealth visits, and in-person appointments to address care gaps, deliver education on chronic conditions, and support medication adherence.
- Conduct post-discharge outreach to evaluate patient understanding of discharge instructions, perform medication reconciliation, monitor symptoms, and confirm follow-up appointments.
- Recognize and escalate care barriers, working closely with providers and care teams to reduce avoidable hospitalizations and emergency visits.
- Collaborate with interdisciplinary staff—including providers, medical assistants, pharmacy teams, and quality improvement specialists—to implement evidence-based practices and improve care workflows.
- Record all patient interactions and clinical outcomes accurately in compliance with regulatory and organizational standards.
- Participate in team huddles, high-risk patient reviews, and quality improvement discussions to support coordinated care planning.
- Support clinic operations through care coordination, provider collaboration, and community wellness events aimed at closing care gaps.
- Maintain strict adherence to patient privacy standards under HIPAA and follow safety and infection control protocols.
- Stay current with clinical guidelines and organizational priorities through ongoing education and team engagement.
Required Qualifications
- Associate’s or Bachelor’s degree in Nursing (ADN or BSN).
- Active, unrestricted Registered Nurse license in the applicable state.
- Minimum of three years of clinical nursing experience, preferably in transitions of care, population health, managed care, or quality improvement.
- Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, Salesforce HealthCloud), and Microsoft Office.
- Willingness to complete and maintain Basic Life Support certification.
Preferred Qualifications
- Familiarity with Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality reporting standards.
- Experience in hospital discharge follow-up or emergency department transition programs.
- Strong clinical judgment and data interpretation skills.
- Effective communication and motivational interviewing techniques to support patient engagement.
- Commitment to patient-centered, equitable care.
- Basic Life Support certification.
- Bilingual proficiency in English and Spanish is strongly preferred.
Work Environment
This is an onsite role requiring presence at the clinic five days per week. Locations include University City and remote sites at Patton Ave and River Hills. Occasional travel within the local market may be required for team meetings or strategic initiatives.
Technology Used
- Athena EMR
- DataHub
- Compass Rose
- Salesforce HealthCloud
- Microsoft Office Suite
Benefits & Growth Opportunities
Clinical Care Nurses receive comprehensive benefits, including medical, dental, and vision coverage, 401(k) with company match, paid time off, disability and life insurance, and eligibility for performance-based bonuses. Additional offerings include flexible scheduling, clinical certification support, leadership development, career coaching, and pathways for professional advancement.
Company Values
The organization is guided by principles of integrity, respect, empathy, and a commitment to health equity. A culture of continuous learning, innovation, and compassionate, patient-centered care supports both clinical excellence and professional growth.
