Clinical Care Nurse (RN)

CenterWell•Surprise, AZ

1d•Onsite

About The Position

The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. The nurse supports safe Transitions of Care (TOC), reduces avoidable emergency department utilization, and advances Medicare Advantage Stars and quality performance. The role proactively identifies care opportunities, engages patients and providers, and drives evidence-based interventions through direct patient education and outreach as well as data-driven quality improvement efforts. The role includes care-transition support and follow-up coordination for discharged inpatient, observation, and emergency department patients; quality performance across Medicare Advantage Stars and HEDIS measures; and culturally appropriate chronic disease education to support self-management, particularly for diabetes, hypertension, congestive heart failure, and COPD. The nurse works with interdisciplinary teams and aligns daily work with organizational values of integrity, respect, empathy, and commitment to health equity. This is an in-center position, five days per week, with a daily commute to assigned clinic(s) and occasional quarterly travel within the market to alternative clinics for strategic meetings. The employee must reside within a reasonable commuting distance of the assigned clinic(s). The schedule is Monday through Friday, 8:00 AM–5:00 PM; additional time may be required. The role is patient-facing and subject to TB screening. It also requires a valid state driver's license and personal vehicle liability insurance meeting applicable requirements. The position is based in the Surprise, Arizona area. The posted annual base-pay range is $71,100–$97,800, with eligibility for a bonus incentive plan based on company and/or individual performance. Humana offers medical, dental, and vision benefits; a 401(k) retirement savings plan; time off, including paid time off and 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 Arizona.
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 Health Cloud, 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 the stated requirements.

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 and data analysis skills, with the 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.
Basic Life Support trained.

Responsibilities

Analyze clinical data and trends in platforms such as Athena EMR and DataHub to identify and prioritize gaps related to 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 in accordance with TOC and Transitional Care Management 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 management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, perform medication reconciliation, monitor symptoms, and support follow-up appointment adherence.
Identify and escalate barriers, collaborating with providers and the care team to prevent readmissions and avoidable emergency department utilization.
Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff to implement evidence-based interventions and optimize workflows.
Document outreach efforts, clinical interactions, outcomes, and patient encounters accurately and promptly in the indicated platform and in compliance with organizational, HIPAA, and CMS requirements.
Prepare for, participate in, and discuss patients during center huddles and high-risk rounds with providers and center-based 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.