Clinical Care Nurse – Florida

About the role

The Clinical Care Nurse (RN) works in two Conviva outpatient clinics in North Miami Beach, Florida, providing post‑discharge support and chronic‑disease education. The role focuses on improving patient outcomes, reducing avoidable emergency‑department visits, and contributing to Medicare Advantage Stars and HEDIS performance.

Key responsibilities

• Identify recently discharged inpatient, observation and ED patients and coordinate timely follow‑up in accordance with Transitions of Care (TOC) and Transitional Care Management (TCM) guidelines.
• Analyze clinical data from Athena EMR and DataHub to pinpoint gaps in care related to Stars, HEDIS, and post‑hospitalization needs.
• Conduct outreach via phone, telehealth and in‑clinic visits to provide education on preventive care, chronic‑disease self‑management (DM, HTN, CHF, COPD) and medication reconciliation.
• Document all interactions, outcomes and escalations accurately in the EMR.
• Collaborate with interdisciplinary teams—including providers, care assistants, medical assistants, pharmacy and quality‑improvement staff—to implement evidence‑based interventions.

Required profile

• Current RN licensure in Florida.
• Experience in care‑transition or population‑health nursing, preferably within a value‑based care setting.
• Strong communication skills for patient and provider engagement.
• Ability to work onsite Monday‑Friday, splitting time between two clinic locations.

Required skills

• Athena EMR
• DataHub analytics platform
• Telehealth technology