Clinical Care Nurse
Healthcare
ClinicalCareNurse
Neural analysis suggests this role is
optimal for Mid candidates.
“Clinical Care Nurse at Clinical Care Nurse. Skills: Transitions of Care, Quality Improvement, Patient Education, EHR Proficiency. Improve patient outcomes. Support safe Transitions of Care”
What You'll Achieve.
Improve patient outcomes; Reduce avoidable ED utilization; Drive Medicare Advantage Stars and quality performance; Prevent avoidable readmissions or return visits; Close care opportunities; Improve clinical performance; Improve patient engagement; Enhance patient health outcomes and satisfaction
Industry & Context.
Clinical judgment; Data analysis skills; Ability to apply evidence-based practices; Identify barriers; Develop innovative solutions
Must reside in designated market area, Valid state driver's license, Maintain personal vehicle liability insurance, TB screening required, In-center presence required
What They're Looking For.
Must Have
Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN), Active, unrestricted RN license, 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), Proficiency with data analytics tools, Proficiency with Microsoft Office Suite, Basic Life Support training
Nice to Have
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements, Experience with Transitions of Care, hospital discharge or ER follow up programs, Clinical judgment, Data analysis skills, Ability to apply evidence-based practices, Excellent communication and motivational interviewing skills, Commitment to health equity, inclusiveness, and patient-centered care, Bilingual in English and Spanish with full professional proficiency, Basic Life Support trained
What You'll Do.
Improve patient outcomes
Support safe Transitions of Care
Reduce avoidable ED utilization
Drive Medicare Advantage Stars and quality performance
Proactively identify care opportunities
Engage patients and providers
Drive evidence-based interventions
Balance direct patient education and outreach
Analyze clinical data and trends
Coordinate timely post-discharge follow-up
Conduct targeted patient and provider outreach
Conduct post-discharge outreach
Collaborate effectively with interdisciplinary teams
Document all outreach efforts
Prepare and discuss patients in center huddles
Participate in quality improvement projects
Monitor progress toward Stars and TCM goals
Support clinic operations
Facilitate center and market-based Wellness Events
Maintain patient confidentiality
Document patient encounters accurately
Follow organizational policies
How You'll Work.
Team & Collaboration
Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff; Prepare, participate 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; Support clinic operations through provider collaboration
Communication Scope
Excellent communication and motivational interviewing skills
Full Job Description
# **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. The Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes. Conviva clinic locations may be available in the following areas: Baytown, Port Arthur, Beaumont As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance 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 DM, HTN, CHF and COPD. **Duties and Responsibilities** : * Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and 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
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