Clinical Care Nurse, RN

Improve patient outcomes through clinical quality and transitions-of-care support Coordinate follow-up for recently discharged inpatient, observation, and emergency department patients Prevent avoidable readmissions and emergency department return visits Analyze clinical data and trends in Athena EMR and DataHub to identify Stars,

HEDIS

, and transition-of-care gaps Conduct patient and provider outreach by phone, telehealth, and in-clinic visits Provide education on preventive care, chronic disease management, medication management, and self-management Perform post-discharge assessment, medication reconciliation, symptom monitoring, and follow-up adherence checks Identify and elevate barriers in collaboration with providers and care teams Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows Document outreach, clinical interactions, patient encounters, and outcomes in compliance with organizational and CMS standards Participate in center huddles and high-risk rounds Participate in quality improvement projects, provider education sessions, and team huddles Monitor Stars and Transitional Care Management goals and develop solutions to improve performance and engagement Support clinic operations, care coordination, community education, and market-based wellness events Maintain patient confidentiality in accordance with HIPAA Follow safety, infection control, attendance, and organizational policies Perform other duties as assigned Requirements Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN) Active, unrestricted RN license in the State of Arizona Bilingual in English and Spanish with full professional proficiency 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management Proficiency with electronic health records such as Athena EMR Proficiency with data analytics tools such as DataHub, Compass Rose, and Salesforce HealthCloud Proficiency with Microsoft Office Suite Willing and able to complete and maintain Basic Life Support training Must reside in the designated market area within reasonable commuting distance to assigned clinics Valid state driver's license Personal vehicle liability insurance meeting specified minimum limits Ability to work Monday–Friday, 8:00 AM–5:00 PM, with additional time as required Core Competencies Demonstrates expertise in clinical quality improvement, care coordination, and patient education, with a strong focus on transitions of care and data analysis. Proficient in utilizing electronic health records and data analytics tools to enhance patient outcomes and support interdisciplinary collaboration. Highest-signal resume keywords Clinical Nursing Experience Transitions Of Care Data Analytics Proficiency Bilingual In English And Spanish Active RN License In Arizona Hard Skills Clinical Quality Improvement Patient Education Medication Reconciliation Symptom Monitoring Data Analysis Care Coordination Chronic Disease Management Preventive Care Quality Improvement Projects Post-Discharge Assessment Soft Skills Collaboration Communication Problem-Solving Patient Outreach Interpersonal Skills Certifications & Qualifications Active RN License Basic Life Support Training Industry Keywords Patient Outcomes Transitions Of Care HEDIS Stars CMS Standards HIPAA Compliance Managed Care Population Health Management Tools & Technologies Athena EMR DataHub Salesforce HealthCloud Microsoft Office Suite #J-18808-Ljbffr Jobtailor