RN Full-time
Conviva Senior Primary Care

Clinical Care Nurse (RN)

Conviva Senior Primary Care Miami, FL, US

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.

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. (strongly preferred)

    • 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 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.

    Share this job

    Share to FB Share to LinkedIn Share to Twitter

    Related Jobs

    RN Director of Nursing Full-time
    HC&N Healthcare Solutions

    Assistant Director of Nursing (RN) / Risk & Staff Development Coordinator

    HC&N Healthcare Solutions Fort Lauderdale, FL
    Assistant Director of Nursing (RN) / Risk & Staff Development Coordinator Long-Term Care Setting A long-term care facility is seeking a Registered Nurse for a leadership position supporting nursing operations, risk oversight, and staff education. This role partners with clinical leadership to help ensure safe, efficient, and high-quality care delivery across the facility. This opportunity is ideal for a nurse with both clinical and administrative experience who enjoys working in a team-focused environment. Position Summary The individual in this role works closely with nursing leadership to help coordinate daily operations, support regulatory compliance, and contribute to risk management initiatives. Responsibilities also include involvement in staff development and maintaining care standards consistent with current healthcare guidelines. Core Responsibilities Assist with coordination of nursing services and daily clinical operations Support implementation of policies aligned with regulatory requirements Participate in risk management activities, including reviewing incidents and identifying trends Contribute to staff education, onboarding, and ongoing training efforts Help maintain quality standards for resident care and documentation Collaborate with interdisciplinary teams to support resident outcomes Provide guidance to nursing staff and promote a positive work culture Assist leadership with administrative and operational tasks as needed Qualifications Active Registered Nurse (RN) license Bachelor’s degree in healthcare-related field preferred (advanced degree a plus) At least 3 years of experience in long-term care or similar setting Prior leadership, supervisory, or administrative experience preferred Familiarity with healthcare regulations and clinical practices in long-term care Strong organizational, communication, and problem-solving skills Comfortable using computer systems and managing documentation What’s Offered Competitive compensation based on experience and education Benefits package including health coverage and 401(k) Supportive and professional work environment Opportunity for continued growth and development Schedule: Based on facility needs A commitment to quality care and respect for every individual is at the core of our mission. We strive to support residents in maintaining independence and well-being while delivering care in a respectful and compassionate environment. Equal Opportunity Employer #HCN123
    RN Home Health Full-time
    The Lakes Home Care

    Registered Nurse Licensed (Portuguese)

    The Lakes Home Care Fort Lauderdale, FL
    We are seeking a dedicated Registered Nurse to join our Home Health team. to assume responsibility and accountability for the application of the nursing process and the delivery of patient care. The Registered Nurse (RN) demonstrates the ability to make clinical judgments in an effective and efficient manner under the direction of the Director of Clinical Services. Responsibilities Utilizes the nursing process to assess, plan, implement and evaluate patient care. Assess signs and symptoms indicating physiologic and psychosocial changes in the patient’s condition. Collects, analyzes, and interprets data and information from health care members and documents actual and/or potential nursing diagnoses. Document the patient’s plan of care using identified nursing diagnoses, expected patient outcomes, and selected nursing interventions. Performs interventions according to identified priorities, plan of care, and the hospital policies and patient care outcome standard. Revises the plan of care according to evaluation, changes in medical plan of care, and effective/ineffective nursing interventions. Uses clinical judgment in evaluation activities to meet patient care needs of an assigned unit/floor including establishing priorities. Other Registered Nurse (RN) duties as assigned. Requirements Current Registered Nurse (RN) License for the state in which the nurse practices. Current Health Certificate (per facility Registered Nurse (RN) contract or state regulation). Current PPD or Chest X-Ray. Current BLS card. One year prior Registered Nurse (RN) experience preferred. The Lakes Benefits: Competitive salary Flexible work hours where you create your own schedule You can expect a 1 patient: 1 nurse ratio, tailored scheduling, and an ideal drive time when you work with The Lakes Home Care . Most importantly, you can expect a rewarding, memorable career when working in a home environment and caring for medically-fragile patients in your community.
    RN Pediatric Med-Surg Full-time
    Nicklaus Children's Health System

    RN- Medical Surgical, Broward (Full Time, Nights)

    Nicklaus Children's Health System Fort Lauderdale, FL
    Description Job Summary Under general supervision, renders professional nursing care in accordance with physicians' treatment plans in order to provide for the comfort and well-being of patients. In doing so, assesses patients' condition, administers prescribed drugs, provides treatments, observes patients' progress, records pertinent observations and reports reaction to drugs and treatments. Assists physicians with examinations and prepares instruments and equipment for physicians' use. Manages and directs nursing care activities, coordinates care planning, collaborates with the clinical and medical staff, and educates patients and their family members on the procedure in a compassionate patient and family centered care environment. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Job Specific Duties Completes all nursing multi-system assessment that includes head to toe, vitals, dressing changes, suction, feeding, bathing, and repositioning. Reviews patient admission history, prepares and accurately completes the discharge planning process as per department and hospital policies & procedures. Communicates the patient's progress including critical findings, changes in the patients' condition with the physician and/or disciplines involved in the care of the child. Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care. Provides nursing care that includes IV site monitoring and troubleshooting, specimen collection, and assists medical team with special procedures. Follows physician’s orders and administers & reconstitutes medications directed. Adheres to the six rights of medication administration. Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care environment. Accesses electronic health record independently according to hospital policy. Completes accurate and timely documentation in the patient’s electronic health record. Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician. Educates patients and their family about disease processes, post treatment home care such as disease, medication, treatments, pain, discharge, and safety. Promotes an 'error free' working environment by consistently providing high-quality, safe care as per hospital policies, conducts prevention rounding, & follows up on identified concerns promptly. Assesses all body systems, ensures safe, effective & efficient care delivery with emphasis on the absence of medication errors, avoidance of falls, ouch-free procedural pain & reduction of pain. Provides patient information and effectively completes the hand off process at shift change and patient reassignments. Qualifications Minimum Job Requirements Graduate of an accredited nursing school (AD in Nursing, RN Diploma, or BSN); or if attended an approved nursing school must have two-years of related acute care hospital experience in the past three years Licensed as a Registered Nurse in the State of Florida, or holds a multi-state nursing license; or able to obtain license prior to start is required - maintain active and in good standing throughout employment American Heart Association BLS - maintain active and in good standing throughout employment American Heart Association PALS - maintain active and in good standing throughout employment Knowledge, Skills, and Abilities BSN degree or currently enrolled in a BSN program. CPI (Crisis Intervention Training) is preferred. National certified preferably within 2 years of hire. Functions as IV champions within 6 months of hire. Ability to work in an acute care setting, demonstrates strong problem solving, critical thinking, and conflict resolution skills. Ability to manage multiple priorities and strong time management skills. Effective verbal and written communication skills. Computer literate. Participates and supports nursing research projects and/or authors/co-authors an evidence-based article within 2 years of hire. Works effectively in a collaborative environment. Flexible and has a passion for learning. Ability to apply principles of evidenced-based practice, analytical thinking, and service excellence in practice. Able to analyze and interpret data and utilize the information to make judgments regarding patient care. Able to float to various nursing units while maintaining the delivery of clinical excellence and high quality service. Able to provide coverage for on-call assignments per department and hospital policy. Job: Nursing - Clinical Department: CS PEDIATRICS MED SURG-2210-760012 Job Status: Professional
    RN Pediatric NICU Full-time
    Nicklaus Children's Health System

    RN- NICU, Coral Springs (Full Time, Nights)

    Nicklaus Children's Health System Fort Lauderdale, FL
    Description Job Summary Under general supervision, renders professional nursing care in accordance with physicians' treatment plans in order to provide for the comfort and well-being of patients. Assesses patients' condition, administers prescribed drugs, provides treatments, observes patients' progress, records pertinent observations and reports reaction to drugs and treatments. Assists physicians with examinations and prepares instruments and equipment for physicians' use. Coordinates care planning, collaborates with the clinical and medical staff, and educates patients and their family members on the procedure in a compassionate patient and family centered care environment. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Job Specific Duties Completes all nursing multi-system assessment that includes head to toe, vitals, dressing changes, suction, feeding, bathing, and repositioning. Reviews patient admission history, prepares and accurately completes the discharge planning process as per department and hospital policies & procedures. Communicates the patient's progress including critical findings, changes in the patients' condition with the physician and/or disciplines involved in the care of the child. Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care. Provides nursing care that includes IV site monitoring and troubleshooting, specimen collection, and assists medical team with special procedures. Follows physician’s orders and administers & reconstitutes medications directed. Adheres to the six rights of medication administration. Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care environment. Accesses electronic health record independently according to hospital policy. Completes accurate and timely documentation in the patient’s electronic health record. Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician. Educates patients and their family about disease processes, post treatment home care such as disease, medication, treatments, pain, discharge, and safety. Promotes an 'error free' working environment by consistently providing high-quality, safe care as per hospital policies, conducts prevention rounding, & follows up on identified concerns promptly. Assesses all body systems, ensures safe, effective & efficient care delivery with emphasis on the absence of medication errors, avoidance of falls, ouch-free procedural pain & reduction of pain. Provides patient information and effectively completes the hand off process at shift change and patient reassignments. Qualifications Minimum Job Requirements Completion of a nursing program from an accredited school of Nursing RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing throughout employment American Heart Association BLS - maintain active and in good standing throughout employment American Heart Association PALS required within 1 year of hire - maintain active and in good standing throughout employment Neonatal Resuscitation Program (NRP) as specified by the department within 1 year of hire American Heart Association ACLS as specified by the department within 1 year of hire Knowledge, Skills, and Abilities CPI (Crisis Intervention Training) is preferred. National certified preferably within 2 years of hire. Functions as IV champions within 6 months of hire. Ability to work in an acute care setting, demonstrates strong problem solving, critical thinking, and conflict resolution skills. Ability to manage multiple priorities and strong time management skills. Effective verbal and written communication skills. Computer literate. Participates and supports nursing research projects and/or authors/co-authors an evidence-based article within 2 years of hire. Works effectively in a collaborative environment. Flexible and has a passion for learning. Ability to apply principles of evidenced-based practice, analytical thinking, and service excellence in practice. Able to analyze and interpret data and utilize the information to make judgments regarding patient care. Float to various nursing units while maintaining the delivery of clinical excellence and high quality service. Coverage for on-call assignments per department and hospital policy. Job: Nursing - Clinical Department: CS NICU-2210-620013 Job Status: Professional
    RN Pediatric Med-Surg Full-time
    Nicklaus Children's Health System

    RN- Medical Surgical, Ft. Lauderdale (Full Time, Nights)

    Nicklaus Children's Health System Fort Lauderdale, FL
    Description Job Summary Under general supervision, renders professional nursing care in accordance with physicians' treatment plans in order to provide for the comfort and well-being of patients. In doing so, assesses patients' condition, administers prescribed drugs, provides treatments, observes patients' progress, records pertinent observations and reports reaction to drugs and treatments. Assists physicians with examinations and prepares instruments and equipment for physicians' use. Manages and directs nursing care activities, coordinates care planning, collaborates with the clinical and medical staff, and educates patients and their family members on the procedure in a compassionate patient and family centered care environment. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Job Specific Duties Completes all nursing multi-system assessment that includes head to toe, vitals, dressing changes, suction, feeding, bathing, and repositioning. Reviews patient admission history, prepares and accurately completes the discharge planning process as per department and hospital policies & procedures. Communicates the patient's progress including critical findings, changes in the patients' condition with the physician and/or disciplines involved in the care of the child. Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care. Provides nursing care that includes IV site monitoring and troubleshooting, specimen collection, and assists medical team with special procedures. Follows physician’s orders and administers & reconstitutes medications directed. Adheres to the six rights of medication administration. Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care environment. Accesses electronic health record independently according to hospital policy. Completes accurate and timely documentation in the patient’s electronic health record. Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician. Educates patients and their family about disease processes, post treatment home care such as disease, medication, treatments, pain, discharge, and safety. Promotes an 'error free' working environment by consistently providing high-quality, safe care as per hospital policies, conducts prevention rounding, & follows up on identified concerns promptly. Assesses all body systems, ensures safe, effective & efficient care delivery with emphasis on the absence of medication errors, avoidance of falls, ouch-free procedural pain & reduction of pain. Provides patient information and effectively completes the hand off process at shift change and patient reassignments. Qualifications Minimum Job Requirements Graduate of an accredited nursing school (AD in Nursing, RN Diploma, or BSN); or if attended an approved nursing school must have two-years of related acute care hospital experience in the past three years Licensed as a Registered Nurse in the State of Florida, or holds a multi-state nursing license; or able to obtain license prior to start is required - maintain active and in good standing throughout employment American Heart Association BLS - maintain active and in good standing throughout employment American Heart Association PALS - maintain active and in good standing throughout employment Knowledge, Skills, and Abilities BSN degree or currently enrolled in a BSN program. CPI (Crisis Intervention Training) is preferred. National certified preferably within 2 years of hire. Functions as IV champions within 6 months of hire. Ability to work in an acute care setting, demonstrates strong problem solving, critical thinking, and conflict resolution skills. Ability to manage multiple priorities and strong time management skills. Effective verbal and written communication skills. Computer literate. Participates and supports nursing research projects and/or authors/co-authors an evidence-based article within 2 years of hire. Works effectively in a collaborative environment. Flexible and has a passion for learning. Ability to apply principles of evidenced-based practice, analytical thinking, and service excellence in practice. Able to analyze and interpret data and utilize the information to make judgments regarding patient care. Able to float to various nursing units while maintaining the delivery of clinical excellence and high quality service. Able to provide coverage for on-call assignments per department and hospital policy. Job: Nursing - Clinical Department: CS PEDIATRICS MED SURG-2210-760012 Job Status: Professional