Clinical Care Nurse (RN)
About The Position
The Clinical Care Nurse is a clinic-based registered nursing role that supports safe transitions of care, reduces avoidable emergency department use, and advances Medicare Advantage Stars, HEDIS, and other quality performance. The nurse identifies care opportunities, engages patients and providers, and delivers evidence-based interventions through patient education, outreach, and data-driven quality improvement. The role supports patients discharged from inpatient, observation, and emergency department settings through follow-up coordination and readmission prevention. It also provides culturally appropriate chronic disease education and self-management support, particularly for diabetes, hypertension, congestive heart failure, and COPD. Work includes phone, telehealth, and in-clinic outreach, as well as travel to members’ residences within 30 to 40 miles. The position requires a private home-office room with a locked door and high-speed DSL or cable internet; satellite internet is not permitted. This is a patient-facing role subject to tuberculosis screening. Associates working in Florida need ACHA Level II Background clearance.
Requirements
- Registered Nurse with at least 2 years of experience in in-home case or care management.
- Experience working with the adult population.
- Knowledge of community health and social service agencies and additional community resources.
- Ability to travel to members’ residences within 30 to 40 miles.
- Exceptional communication and interpersonal skills, including the ability to quickly build rapport.
- Ability to work with minimal supervision within the role and scope.
- Ability to use electronic information applications and software, including electronic medical records.
- Intermediate to advanced computer skills and experience with Microsoft Word, Outlook, and Excel.
- Excellent keyboarding and web navigation skills.
- Ability to work a flexible full-time schedule of at least 40 hours per week.
- Valid state driver’s license, personal vehicle liability insurance meeting applicable requirements, and access to an automobile.
- Must have a separate home-office room with a locked door to ensure continuous privacy while working.
- Must have high-speed DSL or cable internet for the home office; satellite internet is not allowed. A speed of 5 Mbps download/1 Mbps upload is recommended for optimal performance with Humana At Home systems.
- Must complete tuberculosis screening if selected for the patient-facing role.
- Florida-based associates must obtain ACHA Level II Background clearance.
- Passion for contributing to an organization focused on continuously improving consumer experiences.
Nice To Haves
- Bachelor of Science in Nursing (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 and Spanish.
- Certification in Case Management.
- Motivational Interviewing certification and/or knowledge.
Responsibilities
- Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize gaps in Stars, HEDIS, transitions of care, and post-hospitalization needs.
- Identify recently discharged inpatient, observation, and emergency department patients and coordinate timely post-discharge follow-up consistent with TOC and TCM requirements.
- Conduct targeted patient and provider outreach by phone, telehealth, and in-clinic visits to close care opportunities and provide education on preventive care, chronic disease, and medication management.
- Assess patients’ understanding of discharge instructions, reconcile medications, monitor symptoms, and support follow-up appointment adherence; identify and escalate barriers to help prevent readmissions and avoidable ED use.
- Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, quality improvement staff, and other interdisciplinary colleagues to implement evidence-based interventions and optimize workflows.
- Document outreach, clinical interactions, encounters, and outcomes accurately and promptly in the appropriate platform, while complying 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 remain current on clinical guidelines and organizational priorities.
- Monitor progress toward Stars and TCM 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 safety, infection-control, and attendance policies, and perform other duties as assigned.
Benefits
- Medical, dental, and vision benefits.
- 401(k) retirement savings plan.
- Paid time off and company and personal holidays.
- Paid parental and caregiver leave.
- Short-term and long-term disability coverage.
- Life insurance.
- Other benefits and well-being opportunities.
- Bonus incentive plan based on company and/or individual performance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
