Clinical Care Nurse (RN)

CenterWell•Clermont, FL

5d•$71,100 - $97,800•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes through safe Transitions of Care (TOC), reduced avoidable emergency department utilization, and improved Medicare Advantage Stars and quality performance. The nurse identifies care opportunities, engages patients and providers, and supports evidence-based interventions through direct education and outreach as well as data-driven quality improvement. The role promotes integrity, respect, empathy, health equity, and patient satisfaction. The position supports patients discharged from inpatient, observation, and emergency department settings through timely follow-up, care coordination, medication reconciliation, symptom monitoring, and readmission prevention. It also contributes to Stars, HEDIS, and other quality measures across a value-based population and provides culturally appropriate chronic disease education, particularly for diabetes, hypertension, congestive heart failure, and COPD. This is an in-center position based at assigned Conviva clinic locations in Clermont, Florida, with daily clinic attendance five days per week and occasional quarterly travel to alternative clinics within the market. The schedule is Monday through Friday, 8:00 AM to 5:00 PM, with additional time potentially required. The role is patient-facing and subject to TB screening. It requires a valid state driver's license and maintenance of personal vehicle liability insurance. The role pays an estimated base salary of $71,100–$97,800 per year for full-time employment and is eligible for a bonus incentive plan. Humana offers medical, dental, and vision benefits; a 401(k) retirement savings plan; paid time off, company and personal holidays; paid parental and caregiver leave; short- and long-term disability; life insurance; and other benefits.

Requirements

Associate's degree in nursing (ADN) or bachelor's degree in nursing (BSN).
Active, unrestricted RN license in the State of Florida.
At least 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 such as Athena EMR, data analytics tools such as DataHub, Compass Rose, or Salesforce HealthCloud, and Microsoft Office Suite.
Willingness and ability to complete and maintain Basic Life Support training.
Must reside in the designated market area within reasonable commuting distance of assigned clinic(s).
Valid state driver's license and personal vehicle liability insurance meeting applicable requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 AM–5:00 PM, with additional time as needed.
Ability to undergo tuberculosis screening for this patient-facing role.

Nice To Haves

Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Experience with Transitions of Care, hospital discharge, or emergency department 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 English and Spanish proficiency at a full professional level.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends using platforms such as Athena EMR and DataHub to identify and prioritize gaps in Stars, HEDIS, Transitions of Care, and post-hospitalization care.
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.
Conduct targeted outreach to patients and providers by phone, telehealth, and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease management, and medication management.
Assess patients’ understanding of discharge instructions, reconcile medications, monitor symptoms, and support adherence to follow-up appointments; identify and escalate barriers to help prevent readmissions and avoidable emergency department visits.
Collaborate with providers and interdisciplinary teams, including care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff, to implement evidence-based interventions and optimize workflows.
Accurately document outreach, clinical interactions, outcomes, and patient encounters in the appropriate platform and in accordance with organizational, CMS, and HIPAA requirements.
Prepare for, participate in, and discuss patients during center huddles and high-risk rounds with providers and interdisciplinary teams.
Participate in quality improvement projects, provider education sessions, and team huddles to stay current with clinical guidelines and organizational priorities.
Monitor progress toward Stars and Transitional Care Management goals, identify barriers, and help develop 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 and closing Stars care opportunities.
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.