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. The locations supported by this position are: RGV - Edinburg & McAllen 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 of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits. Conduct targeted patient and provider outreach via phone, telehealth and in-clinic 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. 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 to stay current with evolving clinical guidelines and organizational priorities. Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement. Support clinic operations through provider collaboration, care coordination, and community education initiatives. Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures. 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 . Use your skills to make an impact Required Qualifications: Must meet one of the following requirements: 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 . Bilingual in English and Spanish w