Clinical Care Nurse - Houston

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). 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 in 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, bottle-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and elevate 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. Coordinate and facilitate 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 Qualifications Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN). Active, unrestricted RN license (state specific as applicable). 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management. Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer's population health tools), and Microsoft Office Suite. Willing and able to complete and maintain Basic Life Support training. 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. 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, inclusiveness, and patient-centered care. Bilingual in English and Spanish with full professional proficiency. (strongly preferred) Basic Life Support trained. 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. Work Information This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings. Workstyle: Clinic-based, in-center 5 days per week. Location: Must reside in designated market area, in reasonable commutable distance to assigned clinic(s). Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required. TB Statement This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Driving Statement This 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 higher. Scheduled Weekly Hours 40 Pay Range $78,200 - $107,600 per year. This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description Of Benefits Humana, 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. Equal Opportunity Employer It 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 Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. #J-18808-Ljbffr CenterWell Senior Primary Care