RN Full-time
Conviva Senior Primary Care

Clinical Care Nurse (RN)

Conviva Senior Primary Care San Antonio, TX 78213, US
$71,100 - $97,800 / year

Become a part of our caring community and help us put health first
 

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: Thousand Oaks, Kirby

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.

Role Scope  

  • Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients. 

  • Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.  

  • Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.  

Duties and 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 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. Identify and escalate 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 optimize 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 initiatives.  

  • 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. 


    Use your skills to make an impact
     

    Required 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.  

    Preferred Qualifications: 

    • Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements. 

    • Experience with Transitions of Care, hospital discharge or ER follow up programs. 

    • Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices. 

    • Excellent communication and motivational interviewing skills to educate and empower members. 

    • Commitment to health equity, inclusiveness, and patient-centered care. 

    • Bilingual in English and Spanish with full professional proficiency. 

    • Basic Life Support trained. 

    Additional Information

    Core Competencies: 

    • Clinical quality improvement and strategic gap closure. 

    • Transitions of Care coordination and post-discharge support. 

    • Member and provider engagement with motivational interviewing. 

    • Regulatory compliance and documentation accuracy. 

    • Data interpretation and actionable reporting. 

    • Cross-functional collaboration and teamwork. 

    • Time management balancing administrative and outreach duties. 

    Values & Mission Alignment: 

    • Demonstrate integrity, respect, and empathy in all interactions. 

    • Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care. 

    • Champion continuous learning, innovation, and professional growth. 

    Work Information:

    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. 

    • Workstyle: Clinic-based, in-center 5 days per week. 

    • Location: Must reside in designated market area, in reasonable commutable distance to assigned clinic(s). 

    • Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required. 

     

    TB Statement: 

    This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. 

     

    Driving Statement: 

    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 to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their 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.

    Description of Benefits

    Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.


    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 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 creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

    ​
    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.

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Help to advance the practice of nursing and improve positive outcomes for your patients as a (an) Clinical Nurse Coordinator Med Surg Telemetry. We want your knowledge and expertise! Job Summary and Qualifications The Clinical Nurse Coordinator (CNC) ensures and delivers high quality, patient-centered care and coordination of all functions in the unit/department during the designated shift. In collaboration with other members of the management team, the CNC directs, monitors, and evaluates nursing care in accordance with established policies/procedures, serves as a resource person for staff, and models a commitment to the organization’s vision/mission/values to support an unparalleled patient experience and clinical outcomes that contribute to overall departmental performance. What you will do in this role: Assists with admission and discharge processes to ensure efficient throughput and high quality, patient-centered care. Participates in the ongoing assessment of the quality of patient care services provided in the unit, in collaboration with other members of the management team. Collaborates with subject matter experts and other managers to create an environment of teamwork that supports improved outcomes and service. Supports a patient-first philosophy and engages in service recovery when necessary. Supports the efforts of the facility to improve engagement by operationalizing current nursing strategies, including employee rounding, hourly rounds, and other initiatives. Provides recommendations related to interviewing, selecting, and training new staff. Recommends and implements courses of action, including training and development, conflict resolution, personnel policy compliance, completion of performance evaluations, and/or disciplinary actions to ensure a competitively better organization. Assists with staff scheduling. Manages all practical aspects of staff labor in accordance with patient care needs and established productivity guidelines. Supports proper inventory control and assists with managing supplies and equipment. What qualifications you will need: Basic Cardiac Life Support must be obtained within 30 days of employment start date Registered Nurse Associate Degree, or Bachelors Degree, or Registered Nurse Diploma Methodist Hospital Stone Oak is equipped with the most modern technology available. With over 280 beds, services include emergency care, general surgery, obstetrics and gynecology, neonatology, oncology, neurosurgery, orthopedics, and acute rehab services. Methodist Hospital Stone Oak is accredited by the Joint Commission as a Primary Stroke Center and Chest Pain Center. The stroke rehabilitation program has received the Joint Commissions Gold Seal of Approval® for Disease-Specific Care Certification of Stroke Rehabilitation. We belong to the Texas Institute for Robotic Surgery. Our surgeons and technology offer minimally invasive options to patients. Surgeons from around the country come to train under our world class team. The hospital has been recognized by Leapfrog’s Hospital Safety Grade A and by Modern Healthcare as one of the Top 100 Best Places to Work in Healthcare. We have also been recognized as a Joint Commission Top Performer on Key Quality Measures®. Finally, by Medicare.gov as #1 in San Antonio and #6 in the entire nation. The hospital is 1 of only 102 hospitals to receive Medicare.gov’s 5-star rating. Join our team to be part of the innovation. "There is so much good to do in the world and so many different ways to do it." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder Be a part of an organization that leverages our size to make a real impact in our industry! Our Talent Acquisition team is reviewing applications for our Clinical Nurse Coordinator Med Surg Telemetry opening. Submit your application today and help advance the practice of nursing. We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.