MSP-Caregiver 3

MSP-Caregiver 3#26-10517

Charlotte, NC

Onsite

Job Description

Job Summary:

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient

outcomes, supporting safe Transitions of Care (TOC), reducing avoidable ED utilization, and

driving Medicare Advantage Stars and quality performance.

The Clinical Care RN plays a critical role in advancing clinical quality, supporting patients across transitions of care, improving patient outcomes, and contributing to Medicare Advantage Stars

ratings by proactively identifying care opportunities, engaging patients and providers, and

driving evidence-based interventions.

This position balances direct patient education and outreach with data-driven quality

improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational

valuesintegrity, respect, empathy, and commitment to health equityto 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 Diabetes and Hypertension

Duties and Responsibilities:

Analyze clinical data and trends from platforms such as Athena EMR and DataHub to

identify gaps in care related to 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 and telehealth 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 teamsincluding providers, care assistants,

center administrators, medical assistants, pharmacy, and quality improvement staffto

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.

proactively identify barriers, and contribute to developing innovative solutions to improve clinical

performance and patient engagement.

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

Required Qualifications:

Bachelor's degree in Nursing

Active, unrestricted RN license (state-specific as applicable).

Minimum of 3 years clinical nursing experience with exposure to transitions of care,

quality improvement, managed care, or population health management.

Preferred Qualifications:

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality

requirements.

Experience with Transitions of Care, hospital discharge or ER follow up programs.

Proficiency with electronic health records (e.g., Athena EMR), data analytics tools

(DataHub), and Microsoft Office Suite.

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, inclusivity, and patient-centered care.

(Market dependent) Bilingual in English and Spanish or Creole with full professional

proficiency

Core Competencies:

Clinical quality improvement and strategic gap closure

Transitions of Care coordination and post-discharge support

Member and provider engagement with motivational interviewing

Regulatory compliance and documentation accuracy

Data interpretation and actionable reporting

Cross-functional collaboration and teamwork

Time management balancing administrative and outreach duties

Values & Mission Alignment:

Demonstrate integrity, respect, and empathy in all interactions.

Uphold the mission to improve health outcomes and member satisfaction through

proactive, compassionate care.

Champion continuous learning, innovation, and professional growth.

Working Conditions

Workstyle: remote

Hours: Monday-Friday, 8:00 AM-5:00 PM; additional time may be required

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.