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Job Profile
Field Care Manager Nurse 2
Job Level
Professional 2
Become a part of our caring community
The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. You will support safe Transitions of Care (TOC), reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes.
CenterWell/Conviva clinic locations may be available in the following areas: Kingsville, Alice
As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity – to enhance patient health outcomes and satisfaction.
Transitions:Caretransition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient,observationand emergency department patients.
Population Health: Deliver culturallyappropriate chronicdisease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.
Duties and Responsibilities:
Proactivelyidentifyrecently discharged inpatient, observation and emergency department patients and coordinatetimelypost-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes ofutilizationand supporting patients to prevent avoidable readmissions or return visits.
Conduct targeted 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.Identifyand escalate barriers, collaborating with providers and careteamto prevent readmissions and avoidable EDutilization.
Collaborate effectively with interdisciplinaryteams,including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions andoptimizeworkflows.
Use your skills to make an impact
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
Proficiencywith electronic health records (e.g., Athena EMR), data analytics tools (e.g.,DataHub, Compass Rose,SalesForceHealthCloud– per your prior employer’s population health tools), and Microsoft Office Suite.
Preferred Qualifications:
Values & Mission Alignment:
This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.
This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you willbe requiredto be screened for TB.
This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected tomaintainpersonal vehicle liability insurance.Individualmust carry vehicle insurancein accordance withtheir residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Referral Bonus Information
This requisition is not eligible for a referral bonus.
About us
About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana’s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
