Clinical Care Nurse (RN)
$71,100–$97,800 year
On-siteOrange City, Florida, United States
Job Summary
Analyze clinical data from Athena EMR and DataHub to identify care gaps related to Medicare Advantage Stars and HEDIS measures. Proactively identify recently discharged inpatient, observation, and emergency department patients to coordinate timely post-discharge follow-up and prevent avoidable readmissions. Conduct targeted patient and provider outreach via phone, telehealth, and in-clinic visits to close care opportunities and provide education on chronic disease management. Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows while documenting all interactions in compliance with CMS standards. Participate in center huddles, high-risk rounds, and quality improvement projects to stay current with clinical guidelines. This clinic-based role supports Conviva Senior Primary Care's value-based approach to improving patient outcomes and reducing ED utilization.
Required Qualifications
- 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., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer's population health tools), and Microsoft Office Suite
- Willing and able to complete and maintain Basic Life Support training
- Valid state driver's license
- Personal vehicle liability insurance in accordance with residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher
Desired Qualifications
- 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 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
- Bilingual in English and Spanish with full professional proficiency (strongly preferred)
- Basic Life Support trained
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