Bilingual Clinical Care RN: Transitions & Quality

Humana Inc; Tigard (OR); On-site; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. via CenterWell Senior Primary Care seeks a Clinical Care Nurse (RN) to drive transitions of care, reduce avoidable ED visits, and support Medicare Advantage quality goals. This clinic-based role emphasizes patient education, care coordination, and data-driven improvements across DM, HTN, CHF and COPD.

You will work with a multidisciplinary team in a market-focused setting. The ideal candidate holds an ADN or BSN, an active RN license, 3+ years of relevant nursing experience, and

Qualifications

• RN license active and unrestricted; state-specific requirements apply.
• ADN or BSN degree required; BSN preferred for senior roles.
• 3+ years of clinical nursing with exposure to transitions of care or population health.
• Proficient with EHRs (Athena EMR) and data analytics tools (DataHub, Compass Rose, SF HealthCloud).
• Bilingual English/Spanish with full professional proficiency.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS.
• Coordinate post-discharge follow-up to prevent readmissions and support TOC/TCM.
• Outreach patients and providers via phone, telehealth, and in-clinic visits for care opportunities.
• Educate patients on preventive care, chronic disease management, and medications.
• Document outreach and outcomes accurately per CMS standards.
• Collaborate with interdisciplinary teams to optimize workflows and care.
• Contribute to quality improvement projects and provider education.
• Maintain HIPAA-compliant patient confidentiality.

Skills

RN license

Clinical nursing experience

Transitions of care

EHR experience

Bilingual English/Spanish

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

Salesforce HealthCloud

Microsoft Office

Job description

Humana Inc. via CenterWell Senior Primary Care seeks a Clinical Care Nurse (RN) to drive transitions of care, reduce avoidable ED visits, and support Medicare Advantage quality goals. This clinic-based role emphasizes patient education, care coordination, and data-driven improvements across DM, HTN, CHF and COPD.

You will work with a multidisciplinary team in a market-focused setting. The ideal candidate holds an ADN or BSN, an active RN license, 3+ years of relevant nursing experience, and