Clinical Care RN: Transitions & Quality Impact

Humana / CenterWell; Leesburg (FL); On-site; USD 71,000 - 98,000; Full time

Job summary

CenterWell Senior Primary Care in Florida (Leesburg) seeks a Clinical Care RN to improve patient outcomes through care transitions, post-discharge follow-ups, and population health initiatives. You will work with providers and care teams to reduce avoidable ED visits and support Stars performance.

The role requires an ADN or BSN, active RN license, 3+ years in nursing, bilingual English/Spanish, and EMR/data-tool proficiency, with BLS training and strong communication.

Qualifications

• RN license active and unrestricted
• 3+ years clinical nursing with transitions of care, quality improv., or population health
• Bilingual English/Spanish with professional proficiency
• Proficiency with EHR and data analytics tools (Athena EMR, DataHub, Compass Rose, SF HealthCloud)
• Willing to complete Basic Life Support training

Responsibilities

• Analyze clinical data to identify care gaps related to Stars and HEDIS
• Coordinate post-discharge follow-up to prevent readmissions
• Conduct outreach via phone, telehealth, and in-clinic visits
• Educate patients on preventive care and chronic disease management
• Collaborate with interdisciplinary teams to implement interventions
• Document outreach and outcomes per CMS standards
• Participate in quality improvement projects and center huddles

Skills

RN experience

Bilingual English/Spanish

Data interpretation

Communication skills

Motivational interviewing

Education

Associate's degree in nursing (ADN)

Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

CenterWell Senior Primary Care in Florida (Leesburg) seeks a Clinical Care RN to improve patient outcomes through care transitions, post-discharge follow-ups, and population health initiatives. You will work with providers and care teams to reduce avoidable ED visits and support Stars performance.

The role requires an ADN or BSN, active RN license, 3+ years in nursing, bilingual English/Spanish, and EMR/data-tool proficiency, with BLS training and strong communication.