Clinical Care RN: Transitions & Quality Improvement

Humana Inc; Phoenix (AZ); On-site; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off

Short-term and long-term disability

Life insurance

Job summary

Humana Inc. invites a Clinic-based Clinical Care Nurse (RN) to join CenterWell Senior Primary Care in a patient-centered role. You will support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance through targeted education and outreach.

The role emphasizes data-informed care, collaboration with interdisciplinary teams, and maintaining HIPAA compliance while advancing health equity.

Qualifications

• RN with active license in Arizona or eligible
• ADN or BSN required
• 3+ years nursing with transitions of care/QI exposure
• Proficient with EHRs and data tools
• Willing to complete/maintain BLS training

Responsibilities

• Analyze data trends from Athena EMR and DataHub to identify care gaps.
• Identify recently discharged patients and coordinate timely post-discharge follow-up.
• Outreach via phone, telehealth and in-clinic visits for education and care.
• Assess discharge instructions, reconcile medications, and ensure follow-up adherence.
• Collaborate with providers and teams to implement evidence-based interventions.
• Document outreach and outcomes per CMS standards.
• Participate in center huddles and quality improvement activities.
• Monitor Stars/TCM goals and develop solutions to improve performance.
• Support clinic operations through care coordination and community education.
• Coordinate wellness events focused on Stars care opportunities.
• Maintain patient confidentiality per HIPAA.
• Document encounters timely in the designated system.
• Follow safety, infection control, and attendance policies.
• Perform other duties as assigned.

Skills

RN

Bilingual English/Spanish

EHR proficiency

Data analytics tools

Microsoft Office

Education

ADN or BSN

Tools

Athena EMR

DataHub

Compass Rose

SalesForce Health Cloud

Microsoft Office

Job description

Humana Inc. invites a Clinic-based Clinical Care Nurse (RN) to join CenterWell Senior Primary Care in a patient-centered role. You will support safe transitions of care, reduce avoidable ED visits, and drive Medicare Advantage Stars and quality performance through targeted education and outreach.

The role emphasizes data-informed care, collaboration with interdisciplinary teams, and maintaining HIPAA compliance while advancing health equity.