Registered Nurse

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient
outcomes, supporting safe Transitions of Care (TOC), reducing avoidable ED utilization, and
driving Medicare Advantage Stars and quality performance.
The Clinical Care RN plays a critical role in advancing clinical quality, supporting patients across transitions of care, improving patient outcomes, and contributing to Medicare Advantage Stars
ratings by proactively identifying care opportunities, engaging patients and providers, and
driving evidence-based interventions.
This position balances direct patient education and outreach with data-driven quality
improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational
values—integrity, respect, empathy, and commitment to health equity—to enhance patient
health outcomes and satisfaction.

Role Scope
• 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 are chronic disease self-management, particularly in Diabetes and Hypertension
Duties and Responsibilities:
• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to
identify gaps in care related to HEDIS measures and 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, with the aim of
addressing root causes of utilization and supporting patients to prevent avoidable
readmissions or return visits.
• Conduct targeted patient and provider outreach via phone and telehealth 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,
bottles-out medication reconciliation, symptom monitoring, and follow-up appointment
adherence. Identify and escalate barriers, collaborating with providers and 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.
• proactively identify barriers, and contribute to developing innovative solutions to improve clinical
performance and patient engagement.
• 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

Required Qualifications:
• Bachelor’s degree in Nursing
• Active, unrestricted RN license (state-specific as applicable).
• Minimum of 3 years clinical nursing experience with exposure to transitions of care,
quality improvement, managed care, or population health management.
Preferred Qualifications:
• Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality
requirements.
• Experience with Transitions of Care, hospital discharge or ER follow up programs.