Clinical Care Nurse (RN)

Clinical Care RN Overview 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. 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 populations. 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, preventing readmissions or return visits. Conduct targeted patient and provider outreach via phone, telehealth, and in‑clinic visits to close care opportunities, providing 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 teams to prevent readmissions and avoidable ED utilization. Collaborate effectively with interdisciplinary teams, including providers, care assistants, 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 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 to close Stars care opportunities. 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), 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. Bilingual in English and Spanish with full professional proficiency. 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 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, 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 patient facing and part of Humana's Tuberculosis (TB) screening program. If selected, TB screening will be required. Driving Statement This role is part of Humana's driver safety program and requires a valid state driver's license and maintenance of personal vehicle liability insurance meeting state minimum limits or $25,000 bodily injury per person/$25,000 bodily injury per event/$10,000 property damage, whichever is higher. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full‑time employment at the time of posting. $71,100 – $97,800 per year This position is eligible for a bonus incentive plan based on company and/or individual performance. Description Of Benefits Humana, Inc. offers competitive benefits that support whole‑person well‑being, including medical, dental, vision, 401(k) retirement savings, paid time off, disability, life insurance, and more. About Us CenterWell Senior Primary Care provides proactive, preventive care to seniors, with a care model emphasizing personalized experiences, quality engagement, and holistic well‑being. CenterWell is a Humana company focused on integrated healthcare services and whole‑health care for patients. Equal Opportunity Employer Humana does not discriminate on basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. Humana ensures compliance with Title VI and VEVRAA, using valid job requirements for all employment decisions. #J-18808-Ljbffr CenterWell Senior Primary Care