Clinical Care RN

CenterWell Senior Primary Care; Savannah (GA); On-site; USD 71,100 - 97,800; Full time

Benefits offered by this job

401(k) retirement savings

Paid time off

Medical, dental and vision coverage

Job summary

CenterWell Senior Primary Care is seeking a Clinical Care Nurse (RN) to join our team in Savannah, Georgia. This role is vital in supporting patient transitions of care, reducing avoidable emergency department visits, and ensuring high-quality performance in Medicare Advantage Stars. The ideal candidate will have at least 3 years of clinical nursing experience and a passion for improving health outcomes through patient-centered care.

Responsibilities include patient outreach, collaboration with interdisciplinary teams, and utilizing health data analytics to enhance care delivery. Competitive benefits and a supportive work environment are provided.

Qualifications

• Must have an active, unrestricted RN license.
• 3+ years’ clinical nursing experience in transitions of care or population health management.
• Proficiency with electronic health records and data analysis tools.

Responsibilities

• Support transitions of care and prevent avoidable readmissions.
• Conduct patient outreach for education on chronic disease management.
• Collaborate with interdisciplinary teams to improve patient outcomes.

Skills

Quality improvement

Transitional Care

Data analysis

Chronic disease education

Bilingual (English/Spanish)

Education

Associate’s or Bachelor’s degree in nursing

Tools

Athena EMR

Microsoft Office Suite

Job description

Overview

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. Conviva clinic locations may be available in the following areas: CW Victory Heights.

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 in 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 TOC 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, 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 on 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.

Qualifications

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.
• Bilingual in English and Spanish with full professional proficiency (strongly preferred).
• 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 offers competitive benefits that support whole-person well-being. Benefits include medical, dental and vision coverage, 401(k) retirement savings, time off (paid time off, holidays, volunteer time off, parental and caregiver leave), disability, life insurance, and additional opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell provides proactive, preventive care to seniors, including wellness visits, chronic condition management, screenings, minor injury treatment and more. Our care model focuses on personalized experiences and extended time with patients. Our integrated care teams spend more time with patients to improve health outcomes.

About CenterWell, a Humana company: CenterWell focuses on integrated, differentiated experiences centered on patients. CenterWell is part of Humana Inc. Learn more at CenterWell.com.

Equal Opportunity Employer

Humana does not discriminate in employment and complies with applicable laws and regulations to promote equal opportunity in employment. This policy applies to all employment actions.