Clinic-Based RN: Transitions of Care & Quality Improvement

Humana Inc; Portland (TX); On-site; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical, dental & vision benefits

401(k) retirement plan

Paid time off

Job summary

Conviva Senior Primary Care, part of Humana, seeks an experienced Clinical Care RN to improve patient outcomes through coordinated Transitions of Care and quality initiatives. You will engage patients and providers, conduct education, and drive data‑driven improvements across Medicare Advantage Stars programs.

The role requires in-center availability in Texas, with daily patient contact, post-discharge follow-up, and collaboration with an interdisciplinary team to reduce avoidable readmissions

Qualifications

• ADN or BSN required.
• Active, unrestricted RN license in Texas.
• 3+ years of clinical nursing with transitions of care or population health exposure.
• Proficiency with EHRs and data analytics tools (Athena EMR, DataHub, Salesforce HealthCloud) and MS Office.
• Basic Life Support (BLS) certification.

Responsibilities

• Analyze clinical data and trends to identify gaps in care for Stars/HEDIS and TOC.
• Identify recently discharged patients and coordinate timely post-discharge follow-up per TOC/TCM requirements.
• Conduct outreach via phone, telehealth, and in-clinic visits to close care opportunities.
• Perform discharge instruction reviews, medication reconciliation, and adherence follow-up.
• Collaborate with interdisciplinary teams to implement evidence‑based interventions.
• Document outreach and outcomes in the medical record per CMS standards.
• Participate in center huddles, high‑risk rounds, and quality improvement activities.
• Monitor progress toward Stars/TCM goals and propose solutions to barriers.
• Support clinic operations through care coordination and community education.

Skills

Clinical nursing

Data analysis

Communication skills

Motivational interviewing

Health equity

Education

ADN or BSN

Tools

Athena EMR

DataHub

Salesforce HealthCloud

Microsoft Office

Job description

Conviva Senior Primary Care, part of Humana, seeks an experienced Clinical Care RN to improve patient outcomes through coordinated Transitions of Care and quality initiatives. You will engage patients and providers, conduct education, and drive data‑driven improvements across Medicare Advantage Stars programs.

The role requires in-center availability in Texas, with daily patient contact, post-discharge follow-up, and collaboration with an interdisciplinary team to reduce avoidable readmissions