Clinical Care Nurse (RN)

CenterWell•Port Saint Lucie, FL

3d•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, reducing avoidable emergency department use, and improving Medicare Advantage Stars and quality performance. The nurse supports patients after inpatient, observation, and emergency department discharges; identifies care opportunities; engages patients and providers; and delivers evidence-based interventions. The role balances direct education and outreach with data-driven quality improvement across a value-based population. The role includes coordinating timely post-discharge follow-up, assessing patients’ understanding of discharge instructions and medications, supporting chronic disease self-management, and addressing barriers that may lead to readmissions or return visits. The nurse collaborates with providers and interdisciplinary teams, contributes to quality improvement and clinic operations, and documents care in compliance with organizational and CMS requirements. The position supports patients with culturally appropriate education, particularly regarding diabetes, hypertension, congestive heart failure, and COPD, and aligns with organizational values of integrity, respect, empathy, and health equity. This is an in-center role, five days per week, at assigned clinics in East or West Port St. Lucie, Florida. The employee must live within a reasonable commuting distance of the assigned clinic and may travel quarterly to other clinics within the market for strategic meetings. Scheduled hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required. The position is patient-facing and subject to tuberculosis screening. A valid state driver’s license and personal vehicle liability insurance meeting applicable requirements are required. The stated annual base pay range is $71,100–$97,800 for full-time employment. The position is eligible for a bonus incentive plan. Humana offers medical, dental, and vision benefits; a 401(k) retirement savings plan; 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 Registered Nurse (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 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 applicable state minimums or the stated coverage requirements.
Ability to work in-center five days per week, Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional time may be required.
Ability to meet the role's patient-facing tuberculosis screening requirement.

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.
Full professional proficiency in English and Spanish.
Basic Life Support trained.

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 patient and provider outreach by phone, telehealth, and in-clinic visits to close care opportunities and provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, medication reconciliation, symptom monitoring, and follow-up appointment adherence.
Identify and escalate barriers, collaborating with providers and care teams 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, clinical interactions, outcomes, and patient encounters accurately and promptly in the appropriate platform and in compliance 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 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 policies related to safety, infection control, and attendance, and perform other duties as assigned.