Clinical Care RN: Transitions & Quality Mentor

Humana / CenterWell; Florida; On-site; USD 71,000 - 98,000; Full time

Job summary

Conviva Senior Primary Care in Florida is seeking a Clinical Care RN to strengthen transitions of care, reduce avoidable ED visits, and support Medicare Advantage quality initiatives. The role focuses on identifying care opportunities, educating patients, and coordinating post-discharge follow-up with providers in a clinic-based setting.

You will work with multidisciplinary teams, use Athena EMR and DataHub for data-driven care, and participate in quality improvement activities while upholding

Qualifications

• Active, unrestricted RN license in the State of Florida.
• 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 (DataHub, Compass Rose, SalesForce HealthCloud) and MS Office.
• 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 measures and Transitions of Care.
• Coordinate timely post-discharge follow-up and outreach to prevent readmissions and avoidable ED visits.
• Conduct patient and provider outreach via phone, telehealth, and in-clinic visits for education on preventive care and chronic disease management.
• Collaborate with interdisciplinary teams to implement evidence-based interventions and optimize workflows.
• Document outreach and clinical interactions accurately while complying with HIPAA and CMS standards.

Skills

Bilingual English/Spanish

Education

Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN)

Tools

Athena EMR

DataHub

Compass Rose

SalesForce HealthCloud

Microsoft Office

Job description

Conviva Senior Primary Care in Florida is seeking a Clinical Care RN to strengthen transitions of care, reduce avoidable ED visits, and support Medicare Advantage quality initiatives. The role focuses on identifying care opportunities, educating patients, and coordinating post-discharge follow-up with providers in a clinic-based setting.

You will work with multidisciplinary teams, use Athena EMR and DataHub for data-driven care, and participate in quality improvement activities while upholding