Clinical Care Nurse (RN)

Join Our Caring CommunityThe 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.CenterWell clinic locations may be available in the following areas: CW Hampton, CW SE NewportNews.Role ScopeTransitions: 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 in chronic disease self-management, particularly in DM, HTN, CHF and COPD.Duties and ResponsibilitiesAnalyze 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.Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.Support clinic operations through provider collaboration, care coordination, and community education initiatives.Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.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 QualificationsRegistered Nurse with 2 years of experience of in home case/care managementExperience working with the adult populationKnowledge of community health and social service agencies and additional community resourcesAbility to travel to member's residence within 30 to 40 milesExceptional communication and interpersonal skills with the ability to quickly build rapportAbility to work with minimal supervision within the role and scopeAbility to use a variety of electronic information applications/software programs including electronic medical recordsIntermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and ExcelExcellent keyboard and web navigation skillsAbility to work a full-time (40 hours minimum) flexible work scheduleThis role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higherMust have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you workMust have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1MThis role is considered patient facing and is part of Humana At Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.Valid driver's license, car insurance, and access to an automobileAssociates working in the State of Florida will need ACHA Level II Background clearanceMust be passionate about contributing to an organization focused on continuously improving consumer experiencesPreferred QualificationsBSN3-5 years of in home assessment and care coordination experienceExperience with health promotion, coaching and wellnessPrevious managed care experienceBilingual — English, SpanishCertification in Case ManagementMotivational Interviewing Certification and/or knowledgeScheduled Weekly Hours40Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About UsAbout CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient's well-being.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at?CenterWell.com.Equal Opportunity EmployerIt is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation