Advanced Practice Nurse Primary Care

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 RN plays a critical role in advancing clinical quality and supporting patients across transitions to improve 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 self‑management, especially for 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 requirements to prevent avoidable readmissions.

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 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.

Participate in patient huddles and high‑risk rounds with providers and the center‑based and interdisciplinary team.

Engage 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, 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 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). A nursing degree is required.

Active, unrestricted RN license (state specific as applicable).

3+ years of 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 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.

Bilingual in both English and Spanish.

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, 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. Selected candidates will be required to be screened for TB.

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. Individuals must carry vehicle insurance in accordance with state minimum required limits or the specified amounts.

Weekly Hours
40 hours

Pay Range
$71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.

Description of Benefits
Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Benefits include medical, dental and vision coverage, a 401(k) retirement savings plan, paid time off (including paid holidays and volunteer time off), paid parental and caregiver leave, short‑term and long‑term disability, 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, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance individuals with disability or protected veteran status, and bases all employment decisions only on valid job requirements.

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