Clinical Care Nurse (RN)

Conviva Senior Primary Care Saint Lucie West, FL 34986, 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.

Clinic locations are available in the following areas: Florida – East and West Port St. Lucie.

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 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 (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

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, 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

Related Jobs

Part-time

3 weeks ago

Registered Nurse

Martin Coast Rehabilitation and Healthcare Hobe Sound, FL

Registered Nurse (RN) - Martin Coast Rehabilitation and Healthcare Are you a compassionate and dedicated Registered Nurse (RN) looking for a rewarding career opportunity in a five-star rated facility? We are seeking a passionate and committed RN to join our team at Martin Coast Rehabilitation and Healthcare, located in beautiful Hobe Sound, Florida. Job Summary: As a Registered Nurse (RN) with Martin Coast Rehabilitation and Healthcare, you will be responsible for providing top-quality, life-changing care to our residents. You will work collaboratively with our interdisciplinary team to ensure that our residents receive the highest level of care and support. Your duties will include, but are not limited to: Reviewing, communicating, and contributing to the day-to-day functions of Certified Nursing Assistants (CNA) and Personal Care Attendants (PCA) Providing medications by mouth, subcutaneous, or intramuscular injections as ordered Completing wound care as ordered to improve skin integrity Making written and oral reports/recommendations concerning the activities of your shift for continuity of care Communicating with family members of residents as needed in the event of receiving new orders, a change in condition, or a simple check-in to ensure the resident is safe, well, and content Responsibilities: Admit, transfer, and discharge residents Complete accident/incident reports as necessary Chart in electronic files using Point Click Care in an informative and descriptive manner that reflects the care provided as well as residents' responses to care Receive telephone orders from physicians on duty Order prescribed medications, supplies, and equipment as necessary Ensure that narcotics are handled in accordance with federal, state, and local regulations Participate in associate performance evaluations and make recommendations to the Nurse Supervisor Develop work assignments Make daily rounds of your unit/shift to ensure resident safety is a Top Priority Meet with the nursing personnel on your shift a regularly to improve services Administer professional services such as catheterizations, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, etc Attend and participate in all center in-service programs as required Maintain professional competence through participation in continuing education programs, seminars, and training programs Requirements: Must hold a current and valid LPN or RN license in the state employed CPR certification Benefits: Competitive wages Comprehensive healthcare, dental, and vision benefits If you are passionate about delivering exceptional patient care and want to join a dynamic and supportive team, apply today to become a part of our team at Martin Coast Rehabilitation and Healthcare! How to Apply: Apply now to become a part of our team and join us in our mission to provide top-quality, life-changing care to our residents. In accordance with applicable employment and pay transparency requirements, applicants may access additional information regarding employee rights and disclosures by visiting the Florida Clearinghouse at: https://info.flclearinghouse.com/

Hospice Clinical Manager RN

Affinity Hospice Management LLC Saint Lucie, FL

JOB DESCRIPTION SUMMARY The Clinical Manager is responsible for ensuring that patient care is coordinated and managed appropriately. The Clinical Manager is responsible for ensuring that care and services are delivered appropriately and for the supervision of clinical personnel. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES 1. Receives case referrals. Reviews available patient information related to case, including home visits, to determine hospice/home care needs. Assigns appropriate hospice personnel to case as needed. Conferences with MEDICAL DIRECTOR regarding any questions about an individual's eligibility for services. 2. Reviews and evaluates each case through a variety of means such as home visits, conferences, record review and the services provided by clinicians; discusses and verifies impressions, instructs and guides clinicians to promote more effective performance and delivery of quality home care services; and is available at all times during operating hours to assist clinicians as appropriate. 3. Reviews patient's medical diagnosis, prognosis, medications, procedures and clinical course. 4. Performs medical records management and workflow in EMR system 5. Assists clinicians in establishing immediate and long-term therapeutic goals, in setting priorities, and in developing plan of care. 6. Attends case conference meetings with hospice personnel to facilitate coordination of care and discussion of interdisciplinary group involvement. 7. Conducts quarterly record reviews and communicates findings and recommendations to Clinical Director/Director of Patient Care Services and hospice personnel. 8. Assists in the screening and interviewing process of new employees and makes recommendations for employment of individuals. Assists in the orientation of new employees. 9. Assists Clinical Director/Director of Patient Care Services and other supervisory hospice personnel in the planning, implementation and evaluation of inservice and continuing education programs. Assists in the formulating, revising, implementing, and evaluating organization policies, procedures, goals and objectives, both short and long range. 10. Complies with accepted professional standards and principles. 11. Assesses health needs of community and assists in the development of plan(s)/ program(s) to meet needs. Participates in public relation and community activities that promote the organization's role as an effective member of the hospice and health care delivery system. Promotes customer service orientation to all hospice personnel. 12. Participates actively in quality assessment performance improvement teams and activities. 13. Performs other duties and activities as delegated by the Clinical Director/Director of Patient Care Services. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description. POSITION QUALIFICATIONS 1. Registered nurse with current licensure to practice professional nursing in the state. 2. Graduate of NLN accredited school of nursing with a BSN degree is preferred or a minimum of one (1) year experience as a professional nurse within the last three (3) years. 3. Previous experience in hospice/home care setting and with two (2) years management or supervisory experience. Proven ability to work within an interdisciplinary setting. 4. Complies with accepted professional standards and practice. 5. HCHB and Pointcare experience preferred 6. Has excellent observation, good nursing judgment and communication skills. Understands hospice philosophy and issues of death/dying. 7. Understands principles of pain/symptom management. 8. Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order. 9. Complies and maintains current CPR certification. 10. Demonstrates excellent observation, verbal and written communication skills.

Hospice

Full-time

2 days ago

Hospice Admissions Nurse RN

Affinity Hospice Management LLC Saint Lucie, FL

Job Title/Position: Admission RN Reports To: Clinical Director JOB DESCRIPTION SUMMARY The Admission RN plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES Patient Care 1. Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). 2. Provides professional nursing care by utilizing all elements of the nursing process. 3. Assesses and evaluates patient’s status by: A. Writing and initiating plan of care B. Regularly re-evaluating patient and family/caregiver needs C. Participating in revising the plan of care as necessary 4. Initiates the plan of care and makes necessary revisions as patient status and needs change. 5. Uses health assessment data to determine nursing diagnosis. 6. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. 7. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care. 8. Counsels the patient and family in meeting nursing and related needs. 9. Provides health care instructions to the patient as appropriate per assessment and plan. 10. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care. 11. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload. Communication 1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate. 2. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. 3. Communicates with community health related persons to coordinate the care plan. 4. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. 5. Provides and maintains a safe environment for the patient. 6. Assists the patient and family/caregiver and other team members in providing continuity of care. Additional Duties 1. Ensures that arrangements for equipment and other necessary items and services are available. 2. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes. 3. Fulfills the obligation of requested and/or accepted case assignments. 4. Actively participates in quality assessment performance improvement teams and activities.

Hospice

Full-time

1 week ago

Hospice Registered Nurse Overnight On Call

Affinity Hospice Management LLC Saint Lucie, FL

Job Title/Position : Hospice On Call Overnight RN Reports To : Clinical Director JOB DESCRIPTION SUMMARY : The On-Call Hospice RN is responsible for responding to all of the Hospice patient census and their families, as well as handling any referrals or community inquiries outside of office hours (nights, weekends and holidays). The on-call nurse will provide urgent clinical and psychosocial interventions for patients and their families, skilled pain and symptom management and collaboration with providers within and outside of the hospice team to maximize positive patient outcomes. The work of the On-Call Hospice RN provides considerable consideration for independent assessment and judgement in crisis situations, utilizing and consulting with the Hospice Medical Director and administrator on call as indicated. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES : Consistent availability by telephone and email during assigned shifts. Conducts urgent physical and psychosocial assessments of the patient and family during after hours and determines appropriate interventions. Provides and maintains a safe environment for the patient. Provides professional nursing care by utilizing all elements of the nursing process. Provides skilled nursing care focusing on pain control and symptom management. Provides interim guidance to the patient and family regarding diagnosis, medications, treatments and progress. Documents patient care thoroughly and timely. Completes, maintains and submits accurate and relevant clinical documentation regarding patient's condition and care given. Records pain/symptom management changes/outcomes as appropriate. Communicates and collaborates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. Works closely with members of the IDG to provide continuity of care and support for the patient and family. Collaborates with vendors to obtain DME, supplies and medications when needed after-hours. Collaborates with the hospital and other community residential staffing to adjust interventions and plans of care as needed. Conducts after hours hospice admissions as necessary. Participates in mandatory meetings as required. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-services. Fulfills the obligation of requested assignments. Performs other job-related duties as assigned. POSITION QUALIFICATIONS : Understands and is committed to the hospice philosophy of care. Functions effectively as a team member. Holds a comprehensive knowledge of medication, treatment and therapies for pain and symptom management. Visits patients wherever they call home. Consults with physicians, other team members and administrative staff as indicated. Relates to and cares for people from all walks of life in a calm, courteous and professional manner. Maintains client confidentiality in accordance with HIPAA laws and company policy. Graduate of an accredited school of nursing. Maintains current unencumbered license to practice in FLORIDA a as a Registered Nurse. Preferably has two years of experience in hospice, homecare, hospital medical-surgical or oncology nursing. Understands and works within state and federal laws and regulations and nursing scope of practice. Understands documentation requirements and is able to complete documentation in a timely manner. Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order. Must maintain current driver’s license and automobile insurance, providing own transportation. Once an offer of employment is made, it is contingent upon satisfactory references, as requested, and criminal background checks by regulation. Excellent observation, verbal and written communication skills, problem solving skills, basic computer skills, basic math skills and nursing skills per competency checklist. Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.

Hospice

Full-time

1 month ago

Weekend Registered Nurse RN

Affinity Hospice Management LLC Saint Lucie, FL

JOB DESCRIPTION SUMMARY The registered nurse plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES Patient Care 1. Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). 2. Provides professional nursing care by utilizing all elements of nursing process. 3. Assesses and evaluates patient’s status by: A. Writing and initiating plan of care B. Regularly re-evaluating patient and family/caregiver needs C. Participating in revising the plan of care as necessary 4. Initiates the plan of care and makes necessary revisions as patient status and needs change. 5. Uses health assessment data to determine nursing diagnosis. 6. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. 7. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care. 8. Counsels the patient and family in meeting nursing and related needs. 9. Provides health care instructions to the patient as appropriate per assessment and plan. 10. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care. 11. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload. Communication 1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate. 2. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. 3. Communicates with community health related persons to coordinate the care plan. 4. As a mandatory reporter, reports failure to comply with the requirements of the Dept. of Health as required within 14 calendar days, using Dept. of Health forms. 5. Reports suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred. 6. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. 7. Provides and maintains a safe environment for the patient. 8. Assists the patient and family/caregiver and other team members in providing continuity of care. 9. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver. 10. Attends interdisciplinary group meetings. Additional Duties 1. Participates in on-call duties as defined by the on-call policy. 2. Ensures that arrangements for equipment and other necessary items and services are available. 3. Supervises ancillary personnel and delegates responsibilities when required. 4. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes. 5. Fulfills the obligation of requested and/or accepted case assignments. 6. Actively participates in quality assessment performance improvement teams and activities. POSITION QUALIFICATIONS 1. Graduate of an accredited school of nursing 2. Registered Nurse, with a License in good standing to practice. 3. Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years; OR have a baccalaureate degree in nursing and minimum of two (2) years’ experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred. 4. Management experience not required. Responsible for supervising hospice aides. 5. Once an offer of employment is made, it is contingent upon satisfactory references, as requested, and criminal background checks by regulation. 6. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist. 7. Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills. 8. Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order. 9. Possesses and maintains CPR certification (may not be internet based unless the demonstration of skills was hands on and observed by a certified trainer)