Clinical Care Nurse - Florida

About the role

The Clinical Care Nurse (RN) works in a clinic setting to improve patient outcomes through safe transitions of care, reduced emergency department utilization, and support of Medicare Advantage Stars performance. Based in North Miami Beach, Florida, the role blends direct patient education with data‑driven quality improvement.

Key responsibilities

• Analyze clinical data from Athena EMR and DataHub to identify gaps related to Stars, HEDIS, and transitions of care.
• Proactively reach out to recently discharged patients for post‑discharge follow‑up, medication reconciliation, and symptom monitoring.
• Conduct patient and provider outreach via phone, telehealth, and in‑clinic visits to close care gaps and provide chronic disease education.
• Collaborate with interdisciplinary teams—including providers, medical assistants, pharmacy, and quality improvement staff—to implement evidence‑based interventions.
• Document all interactions accurately in compliance with CMS and organizational standards.

Required profile

• Registered Nurse (RN) license with experience in care transitions and population health.
• Strong understanding of Medicare Advantage quality metrics (Stars, HEDIS).
• Ability to communicate culturally appropriate education for chronic conditions such as diabetes, hypertension, CHF, and COPD.
• Detail‑oriented with excellent documentation skills.

Required skills

• Athena EMR
• DataHub
• Telehealth platforms
• Transitional Care Management (TCM) processes