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.
CenterWell clinic locations may be available in the following areas: CW Hampton, CW SE NewportNews
As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity - to enhance patient health outcomes and satisfaction.
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 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 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, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate 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.
- Coordination and facilitation of 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.
Use your skills to make an impact Required Qualifications- Registered Nurse with 2 years of experience of in home case/care management
- Experience working with the adult population
- Knowledge of community health and social service agencies and additional community resources
- Ability to travel to member's residence within 30 to 40 miles
- Exceptional communication and interpersonal skills with the ability to quickly build rapport
- Ability to work with minimal supervision within the role and scope
- Ability to use a variety of electronic information applications/software programs including electronic medical records
- Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel
- Excellent keyboard and web navigation skills
- Ability to work a full-time (40 hours minimum) flexible work schedule
- 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
- Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work
- Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1M
- This role is considered patient facing and is part of Humana At Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
- Valid driver's license, car insurance, and access to an automobile
- Associates working in the State of Florida will need ACHA Level II Background clearance
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications- BSN
- 3-5 years of in home assessment and care coordination experience
- Experience with health promotion, coaching and wellness
- Previous managed care experience
- Bilingual - English, Spanish
- Certification in Case Management
- Motivational Interviewing Certification and/or knowledge
Additional InformationScheduled Weekly Hours40
Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of BenefitsHumana, 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.
