Clinical Care Nurse (RN)

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.

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.
• Excellent communication and motivational interviewing skills to educate and empower members.
• Commitment to health equity, inclusiveness, and patient-centered care.
• Bilingual in English and Spanish with full professional proficiency (strongly preferred).
• 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, in reasonable commutable distance to assigned clinic(s).
• Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required.

Pay

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

Benefits

Humana offers competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.