Clinical Care Nurse (RN)
$71,100–$97,800 year
On-sitePort Orange, 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 coordinate post-discharge follow-up for inpatient, observation, and emergency department patients to prevent avoidable readmissions. Conduct targeted patient and provider outreach via phone, telehealth, and in-clinic visits to deliver education on chronic disease management and medication reconciliation. Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows for quality improvement projects. Document all outreach efforts and clinical interactions accurately while participating in center huddles and high-risk rounds. Maintain patient confidentiality and support clinic operations through community education initiatives and wellness events.
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
- Must reside in designated market area, in reasonable commutable distance to assigned clinic(s)
- Monday–Friday, 8:00 AM–5:00 PM; additional time may be required
- In-center presence, involving daily commute to assigned clinic(s)
- Occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings
- Required to be screened for TB
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
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.