Role Scope

• Transitions:Caretransition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observationand emergency department patients.

• Quality: Medicare Advantage Stars, HEDIS and quality performance across value-basedpopulation.

• Population Health: Deliver culturallyappropriate chronicdisease education to activate patients are 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 andDataHubtoidentifygaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.

• Proactivelyidentifyrecently discharged inpatient, observation and emergency department patients and coordinatetimelypost-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes ofutilizationand 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.Identifyand escalate barriers, collaborating with providers and careteamto prevent readmissions and avoidable EDutilization.

• Collaborate effectively with interdisciplinaryteams,including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staffto implement evidence-based interventions andoptimizeworkflows.

• Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.

• Prepare,participateand discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.

• Participatein quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.

• Monitorprogress toward Stars and Transitional Care Management goals, proactivelyidentifybarriers, 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.

• Maintainpatient confidentialityin accordance withHIPAA.

Required Qualifications:

• Must meet one of the following requirements: Associates degree in nursing (ADN) or Bachelors degree in nursing (BSN).

• Active, unrestricted RN license (state specificas applicable).

• 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.

• Proficiencywith electronic health records (e.g., Athena EMR), data analytics tools (e.g.,DataHub, Compass Rose,SalesForceHealthCloud per your prior employers population health tools), and Microsoft Office Suite.

• Willing and able to complete andmaintainBasic Life Supporttraining.

Preferred Qualifications:

• Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.

This role is part of Humanas driver safety program and therefore requires an individual to have a valid state drivers license and are expected tomaintainpersonal vehicle liability insurance. Individualmust carry vehicle insurancein accordance withtheir 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.