Clinical Care Nurse, RN

• Improve patient outcomes through clinic-based nursing care
• Support safe Transitions of Care and reduce avoidable emergency department utilization and readmissions
• Drive Medicare Advantage Stars, HEDIS, and quality performance
• Analyze clinical data and trends in Athena EMR, Data Hub, and related platforms to identify and prioritize care gaps
• Identify recently discharged inpatient, observation, and emergency department patients
• Coordinate timely post-discharge follow-up in alignment with TOC and TCM requirements
• Conduct patient and provider outreach by phone, telehealth, and in-clinic visits
• Provide education on preventive care, chronic disease management, medication management, and self-management for diabetes, hypertension, CHF, and COPD
• Perform post-discharge assessments, medication reconciliation, symptom monitoring, and follow-up adherence checks
• Identify and elevate barriers and collaborate with providers and care teams to prevent readmissions and avoidable ED utilization
• Collaborate with providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff
• Document outreach, clinical interactions, outcomes, and patient encounters accurately and timely in compliance with organizational and CMS standards
• Participate in center huddles, high-risk rounds, quality improvement projects, provider education sessions, and team huddles
• Monitor progress toward Stars and TCM goals and develop solutions to improve performance and engagement
• Support clinic operations, care coordination, and community education initiatives
• Coordinate and facilitate in-person Wellness Events for Stars care opportunity closures
• Maintain patient confidentiality in accordance with HIPAA
• Follow safety, infection control, attendance, and organizational policies
• Perform other duties as assigned

• Associate's degree in nursing (ADN) OR Bachelor's degree in nursing (BSN)
• Active, unrestricted RN license in the State of Florida
• 3+ years' 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
• Proficiency with data analytics tools, such as Data Hub, Compass Rose, and Sales Force Health Cloud
• Proficiency with Microsoft Office Suite
• Willing and able to complete and maintain Basic Life Support training
• Must reside in the designated market area, within reasonable commuting distance to assigned clinics
• Valid state driver's license
• Personal vehicle liability insurance meeting state minimum limits or specified Humana limits
• Preferred:
  Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements
• Preferred:
  Experience with Transitions of Care, hospital discharge, or ER follow-up programs
• Preferred:
  Strong clinical judgment, data analysis skills, and evidence-based practice
• Preferred:
  Excellent communication and motivational interviewing skills
• Preferred:
  Commitment to health equity, inclusiveness, and patient-centered care
• Preferred:
  Bilingual English and Spanish with full professional proficiency
• Preferred:
  Basic Life Support trained
• Required TB screening if selected

Demonstrates expertise in clinical nursing care, focusing on transitions of care, quality improvement, and patient education. Proficient in data analysis and electronic health records to enhance patient outcomes and support care coordination.

• Active RN License in Florida
• Clinical Nursing Experience (3+ Years)
• Proficiency in Athena EMR
• Data Analytics Skills
• Knowledge of Medicare Advantage Stars and HEDIS

• Clinical Nursing Care
• Transitions of Care
• Quality Improvement
• Medication Reconciliation
• Chronic Disease Management
• Data Analysis
• Patient Education
• Symptom Monitoring
• Care Coordination
• Preventive Care

• Excellent Communication Skills
• Motivational Interviewing Skills
• Strong Clinical Judgment
• Commitment to Health Equity
• Inclusiveness

• Basic Life Support Training
• Active RN License
• TB Screening

• Medicare Advantage Stars
• HEDIS
• CMS Quality Requirements
• Patient-Centered Care
• Population Health Management

• Athena EMR
• Data Hub
• Sales Force Health Cloud
• Microsoft Office Suite