Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement

Job Title: Clinical Care Nurse (RN): Quality Improvement, Transitions of Care, and Clinical Engagement
Location : Work From Home (Arizona)
Duration: 3 Months (Opportunity for Ext./Conversion but NOT Guaranteed and based off team need)
Shift : M-F 8a-5p (local time) additional time may be required

Job Summary:
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 valuesintegrity, respect, empathy, and commitment to health equityto enhance patient health outcomes and satisfaction.

Role Product
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 teamsincluding providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staffto 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

Core Competencies:
Clinical quality improvement and strategic gap closure
Transitions of Care coordination and post-discharge support
Member and provider engagement with motivational interviewing
Regulatory compliance and documentation accuracy
Data interpretation and actionable reporting
Cross-functional collaboration and teamwork
Time management balancing administrative and outreach duties

Values & Mission Alignment:
Demonstrate integrity, respect, and empathy in all interactions.
Uphold the mission to improve health outcomes and member satisfaction through
proactive, compassionate care.
Champion continuous learning, innovation, and professional growth.

Required Qualifications:
Bachelors 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.
Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (DataHub), and Microsoft Office Suite.
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, inclusivity, and patient-centered care.
(Market dependent) Bilingual in English and Spanish or Creole with full professional proficiency