Clinical Care RN: Transitions & Quality Improvement

humana; Jacksonville (FL); On-site; USD 75,000 - 95,000; Full time

Job summary

CenterWell/Conviva seeks a Clinical Care RN to support safe transitions of care, reduce avoidable ED use, and drive Medicare Advantage Stars. You will analyse data, coordinate post-discharge follow-up, and educate patients on preventive and chronic disease management across DM, HTN, CHF, and COPD.

The role emphasizes collaboration with interdisciplinary teams, participation in huddles, and ongoing quality improvement aligned with CMS requirements.

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.

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 Transitions of Care 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 target 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, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and elevate 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 off 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.
• Coordination and facilitation of center and market-based Wellness Events-focused 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 .

Skills

RN license

Clinical nursing experience

EHR proficiency

Data analytics tools

Microsoft Office Suite

BLS training

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Job description

CenterWell/Conviva seeks a Clinical Care RN to support safe transitions of care, reduce avoidable ED use, and drive Medicare Advantage Stars. You will analyse data, coordinate post-discharge follow-up, and educate patients on preventive and chronic disease management across DM, HTN, CHF, and COPD.

The role emphasizes collaboration with interdisciplinary teams, participation in huddles, and ongoing quality improvement aligned with CMS requirements.