Clinical Care RN: Transitions of Care & Quality Impact

Humana, Inc.; Norfolk (VA); On-site; USD 71,000 - 98,000; Full time

Job summary

Humana, Inc. CenterWell Senior Primary Care is actively seeking a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance.

The role involves patient education, outreach, and data-driven quality initiatives across designated Virginia centers. You will coordinate post-discharge follow-ups, perform targeted outreach by phone/telehealth/in-person visits, and collaborate with providers and care teams to close

Qualifications

• Associate's or Bachelor's degree in nursing.
• Active, unrestricted RN license in Virginia.
• 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
• Proficiency with electronic health records and data analytics tools; MS Office Suite.
• Willing and able to complete and maintain Basic Life Support training.

Responsibilities

• Analyze clinical data and trends to identify gaps in care related to Stars and HEDIS.
• Coordinate timely post-discharge follow-up in alignment with TOC and TCM requirements.
• Outreach to patients and providers via phone, telehealth and in-clinic visits to close care opportunities.
• Assess discharge instructions comprehension and medication reconciliation post-discharge.
• Collaborate with interdisciplinary teams to implement evidence-based interventions.
• Document outreach, interactions and outcomes in systems per CMS standards.
• Participate in center huddles and high-risk rounds with the care team.
• Support quality improvement projects and provider education sessions.

Skills

RN License

Clinical nursing

EHR (Athena EMR)

Data analytics tools

Basic Life Support

Bilingual (English/Spanish)

MS Office

Education

ADN or BSN

Tools

Athena EMR

DataHub

SalesForce HealthCloud

Compass Rose

Microsoft Office

Job description

Humana, Inc. CenterWell Senior Primary Care is actively seeking a Clinical Care Nurse (RN) to support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance.

The role involves patient education, outreach, and data-driven quality initiatives across designated Virginia centers. You will coordinate post-discharge follow-ups, perform targeted outreach by phone/telehealth/in-person visits, and collaborate with providers and care teams to close