Clinical Care Nurse (RN) - Jacksonville (DunnAvenue)

Become a part of our caring community   The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. You will support safe Transitions of Care (TOC), reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes. CenterWell/Conviva clinic locations may be available in the following areas: Dunn Avenue As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity – to enhance patient health outcomes and satisfaction. Role Scope    Transitions:   Care   transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient,   observation   and emergency department patients.   Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based   population .    Population Health: Deliver culturally   appropriate chronic   disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD .    Duties and Responsibilities :   Analyze clinical data and trends from platforms such as Athena EMR and   DataHub   to   identify   gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.   Proactively   identify   recently discharged inpatient, observation and emergency department patients and coordinate   timely   post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of   utilization   and supporting patients to prevent avoidable readmissions or return visits.   Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.   Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence.   Identify   and escalate barriers, collaborating with providers and care   team   to prevent readmissions and avoidable ED   utilization .    Collaborate effectively with interdisciplinary   teams,   including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and   optimize   workflows.   Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.   Prepare,   participate   and discuss patients in center huddles and high - risk rounds with providers and the center-based and interdisciplinary team .    Participate   in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.   Monitor   progress toward Stars and Transitional Care Management goals, proactively   identify   barriers, and help develop innovative solutions to improve clinical performance and patient engagement.   Support clinic operations through provider collaboration, care coordination, and community education initiatives.   Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.   Maintain   patient confidentiality   in accordance with   HIPAA .    Document patient encounters accurately and   timely   in the indicated platform (e.g., medical   record ) .    Follow organizational policies related to safety, infection control, and attendance .    Perform other duties as assigned .   Use your skills to make an impact   Required Qualifications:   Must meet one of the following requirements: Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN). Active, unrestricted RN license ( state specific   as applicable) .  3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management .   Proficiency   with electronic health records (e.g., Athena EMR), data analytics tools ( e.g.,   DataHub , Compass Rose,   SalesForce   HealthCloud  – per your prior employer’s population health tools ), and Microsoft Office Suite.   Willing and able to complete and   maintain   Basic Life Support   training.   Preferred Qualifications:   Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.   Experience with Transitions of Care, hospital discharge or ER   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.   Basic Life Support   trained .   Additional Information Core Competencies:   Clinical quality improvement and strategic gap closure .   Transitions of Care coordination and post-discharge support .   Member and provider engagement with motivational interviewing .   Regulatory compliance and documentation accuracy .   Data interpretation and actionable reporting .   Cross-functional collaboration and teamwork .   Time management   balancing   administrative and outreach duties .   Values & Mission Alignment:   Demonstrate integrity, respect, and empathy in all interactions.   Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.   Champion continuous learning, innovation, and professional growth.   Work Information: This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.   Workstyle: Clinic-based, in-center 5 days per week .   Location: Must   reside   in designated market area,   in   reasonable commutable distance to assigned clinic(s) .   Hours: Monday–Friday, 8:00 AM–5:00 PM;   additional   time may be   required .    TB Statement :   This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will   be required   to be screened for TB.    Driving Statement :   This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to   maintain   personal vehicle liability insurance.   Individual   must carry vehicle insurance   in accordance with   their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.   Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.  $71,100 - $97,800 per year   This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About Us   About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana’s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com. ​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.