Clinical Care Nurse

Become a part of our caring community as a clinic-based Clinical Care Nurse (RN) 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. This role plays a critical role in advancing clinical quality and supporting patients across transitions of care.

CenterWell/Conviva clinic locations may be available in Seneca, SC.

About the Role

The Clinical Care RN contributes 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 while aligning daily responsibilities with organizational values: integrity, respect, empathy, and commitment to health equity.

• 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 for DM, HTN, CHF, and COPD.

Responsibilities

• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars, HEDIS measures, and Transitions of Care, 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 to address root causes of utilization and 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.
• Perform 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 teams 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 in, and discuss patients in center huddles and high-risk rounds with providers and the center-based 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 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.

Requirements

• Must meet one of the following requirements:
  • Associate's degree in nursing (ADN), or
  • Bachelor's degree in nursing (BSN).
• Active, unrestricted RN license in the State of South Carolina.
• 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.
• Bilingual in English and Spanish (preferred).

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 the 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.

This role is considered patient-facing and requires Tuberculosis (TB) screening. If selected, you will be required to be screened for TB.

This role requires a valid state driver's license and maintenance of 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).

Pay

The pay range for this full-time (40 hours per week) role is $71,100 - $97,800 per year. The range may be higher or lower based on geographic location, and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications. This role is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits designed to support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off (including paid holidays, parental, and caregiver leave).
• Short-term and long-term disability.
• Life insurance.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, and minor injury treatment. Our unique care model focuses on personalized experiences, taking time to listen, learn, and address factors impacting patient well-being. Integrated care teams—including physicians, nurses, and behavioral health specialists—spend up to 50% more time with patients, delivering compassionate, personalized care for better health outcomes. We address physical health and other factors influencing patient well-being.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated, differentiated experiences that prioritize patient-centered care. As the largest provider of senior-focused primary care, a leading provider of home healthcare, and a top integrated home delivery, specialty, hospice, and retail pharmacy provider, CenterWell emphasizes whole health—addressing physical, emotional, and social wellness. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more at CenterWell.com.