Bilingual Clinical Care Nurse (RN)

Job title: Bilingual Clinical Care Nurse (RN)

About the Role 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 RN collaborates across care teams to advance clinical quality and support patients across transitions of care.

What You'll Do

• Analyze clinical data from Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and TOC and post-hospitalization needs, prioritizing high-impact opportunities.
• Proactively identify recently discharged inpatients, observation and ED patients and coordinate timely post-discharge follow-up in line with TOC and TCM requirements to prevent readmissions.
• Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease management, and medication management.
• Conduct post-discharge outreach to assess understanding of discharge instructions, medication reconciliation, symptom monitoring, and appointment adherence; escalate barriers and collaborate with providers to prevent readmissions and avoidable ED use.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows; document outreach and encounters accurately per CMS standards.
• Prepare and participate in center huddles and high-risk rounds; participate in quality improvement projects and ongoing education.
• Monitor progress toward Stars and TCM goals, identify barriers, and help develop solutions; support clinic operations through care coordination and community education.
• Coordinate center and market-based Wellness Events focused on in-person engagement for Stars opportunity closures; maintain HIPAA confidentiality.
• Document patient encounters in the designated EMR and follow organizational safety and infection control policies.
• Perform other duties as assigned.

What We're Looking For

• ADN or BSN (or equivalent).
• Active, unrestricted RN license (state-specific).
• 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 (Athena EMR), data analytics tools (DataHub, Compass Rose, Salesforce HealthCloud) and Microsoft Office Suite.
• Willing and able to complete and maintain Basic Life Support training (BLS).

Nice to Have

• Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, 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.
• Basic Life Support trained.