Clinical Care Nurse (RN)

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. Location CenterWell/Conviva clinic locations in Grove Park and Greenbriar 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 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, Transitions of Care, and post‑hospitalization needs. Proactively identify recently discharged patients and coordinate timely post‑discharge follow‑up to address root causes of utilization and support readmission prevention. Conduct targeted patient and provider outreach via phone, telehealth, and in‑clinic visits to close care opportunities and provide tailored education on preventive care, chronic disease management, and medication management. Conduct post‑discharge outreach to assess understanding of discharge instructions, medication reconciliation, symptom monitoring, and follow‑up appointment adherence; identify and escalate barriers, collaborating with providers and care team. Collaborate effectively with interdisciplinary teams 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. Participate in patient discussion at center huddles and high‑risk rounds with providers and the interdisciplinary team. Participate in quality improvement projects, provider education sessions, and 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 on Stars care opportunity closures. Maintain patient confidentiality in accordance with HIPAA. Document patient encounters accurately and timely in the indicated platform. 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), 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. 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 Workstyle: Clinic‑based, in‑center 5 days per week. Location: Must reside in designated market area within 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 part of Humana’s Tuberculosis (TB) screening program. If selected, you will be required to be screened for TB. Driving Statement This role requires an individual to have a valid state driver’s license and to maintain personal vehicle liability insurance in accordance with the resident state’s minimum requirements. Weekly Hours 40 hours per week. Pay Range The compensation range reflects a good faith estimate of starting base pay for full‑time employment at the time of posting. The range may vary based on geographic location and individual qualifications. Benefits Humana offers medical, dental, and vision benefits, a 401(k) retirement savings plan, paid time off (including holidays and volunteer time off), paid parental and caregiver leave, disability insurance, life insurance, and 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. Humana also takes affirmative action to employ and advance individuals with disability or protected veteran status, and bases all employment decisions only on valid job requirements. #J-18808-Ljbffr