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Clinical Care Nurse - Houston

CenterWell Home Health · League City, TX Full Time

Job Description

Become a part of our caring community 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 Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes. Conviva clinic locations may be available in the following areas: Houston, TX (Jacinto City) As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity – to 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 DM, HTN, CHF and COPD. Duties and Responsibilities : Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and 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, telehealth and in-clinic 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 teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to 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. Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.

This is a preview of the job listing. The full posting includes complete compensation details, benefits package, qualification requirements, and application instructions.

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What Most Job Listings Don’t Tell You

General overview for this role type — specific duties and requirements vary by employer.

Support roles in senior living — housekeeping, maintenance, activities, and social work — are far more resident-facing than similar positions in other industries. Housekeepers and maintenance staff interact with residents in their personal living spaces daily, which requires discretion, patience, and genuine respect for the people who live there. In Texas, even non-clinical staff must complete facility-specific training on topics like abuse prevention, infection control, and emergency procedures.

Activities coordinators and social workers play a direct role in resident well-being — isolation and depression are significant concerns in senior living, and programming that keeps residents socially engaged has measurable health outcomes. Maintenance staff in senior care need to understand life-safety systems (fire alarms, emergency generators, call systems) and are often the first responders for building emergencies. Background checks are required for all positions, and many facilities prefer candidates who have previous experience working with older adults.

What to Expect in This Role Day-to-Day

Based on typical senior living facilities in the Houston area.

For housekeeping roles, the day follows a room-by-room schedule — cleaning resident rooms, sanitizing common areas, managing laundry, and responding to spill or accident cleanups as they happen. Infection control protocols are more rigorous than in hotels or commercial cleaning, especially during flu season or respiratory illness outbreaks.

Maintenance staff handle a daily work order queue — everything from changing light bulbs and fixing call buttons to HVAC maintenance and plumbing repairs. Life-safety equipment checks (fire extinguishers, exit lighting, generator testing) happen on set schedules. Activities professionals plan and lead group programming — exercise classes, crafts, music sessions, outings — and also provide one-on-one engagement for residents who cannot participate in group settings. Social workers manage care conferences, discharge planning, family mediation, and community resource referrals. Across all these roles, the common thread is that you become a familiar, trusted presence in residents' daily lives.

About This Employer

CenterWell Home Health is a Parent Agency located in League City, TX at 3027 Marina Bay Drive, Suite 107. This facility holds a 4.6-star Google rating based on 24 reviews.

Care services offered: Licensed And Certified Home Health Services; Licensed Home Health Services

View Full CenterWell Home Health Profile → See all openings at CenterWell Home Health →

Employer profile provided by Houston Senior Living Guide

Houston Area Salary Data

According to the Bureau of Labor Statistics, Home Health and Personal Care Aide positions in the Houston metro area earn a median wage of $11.27/hr ($23,442/yr). The typical range is $10.92 – $13.35/hr (25th–75th percentile).

Entry Level (10th) $22,235/yr

Houston Median $23,442/yr

Experienced (90th) $31,928/yr

vs. National Median -34.5%

Source: Bureau of Labor Statistics, Occupational Employment & Wage Statistics (Houston-Pasadena-The Woodlands, TX Metro Area). Salary data provided by Houston Senior Living Guide.