care nurse rn

CenterWell

<div><h1 class="jobSectionHeader"><b>Become a part of our caring community</b><br>
</h1>
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.
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CenterWell/Conviva clinic locations may be available in the following areas: Stone Mountain, Suwanee<br>
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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 &ndash; to enhance patient health outcomes and satisfaction.<p></p><div><div><p><b>
Role Scope</b></p></div><div><ul><li><p>
Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients.</p></li></ul></div><div><ul><li><p>
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.</p></li></ul></div><div><ul><li><p>
Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.</p></li></ul></div><p></p><div><p><b>
Duties and Responsibilities</b>:</p></div><div><ul><li><p>
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.</p></li></ul></div><div><ul><li><p>
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.</p></li></ul></div><div><ul><li><p>
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.</p></li></ul></div><div><ul><li><p>
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.</p></li></ul></div><div><ul><li><p>
Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff&mdash;to implement evidence-based interventions and optimize workflows.</p></li></ul></div><div><ul><li><p>
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.</p></li></ul></div><div><ul><li><p>
Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.</p></li></ul></div><div><ul><li><p>
Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.</p></li></ul></div><div><ul><li><p>
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.</p></li></ul></div><div><ul><li><p>
Support clinic operations through provider collaboration, care coordination, and community education initiatives.</p></li></ul></div><div><ul><li><p>
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.</p></li></ul></div><div><ul><li><p>
Maintain patient confidentiality in accordance with HIPAA.</p></li></ul></div></div><div><ul><li><p>
Document patient encounters accurately and timely in the indicated platform (e.g., medical record).</p></li></ul></div><div><ul><li><p>
Follow organizational policies related to safety, infection control, and attendance.</p></li></ul></div><div><ul><li><p>
Perform other duties as assigned.</p></li></ul></div><p></p><h1 class="jobSectionHeader"><b><br>
Use your skills to make an impact</b><br>
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</b></h1><div><div><p><b>Required Qualifications:</b></p></div><div><ul><li><p>
Must meet one of the following requirements: Associate&rsquo;s degree in nursing (ADN) or Bachelor&rsquo;s degree in nursing (BSN).</p></li></ul></div><div><ul><li><p>
Active, unrestricted RN license (state specific as applicable).</p></li></ul></div><div><ul><li><p>
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.</p></li></ul></div><div><ul><li><p>
Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud &ndash; per your prior employer&rsquo;s population health tools), and Microsoft Office Suite.</p></li></ul></div><div><ul><li><p>
Willing and able to complete and maintain Basic Life Support training.</p></li></ul></div><p></p><div><p><b>
Preferred Qualifications:</b></p></div><div><ul><li><p>
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.</p></li></ul></div><div><ul><li><p>
Experience with Transitions of Care, hospital discharge or ER follow up programs.</p></li></ul></div><div><ul><li><p>
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.</p></li></ul></div><div><ul><li><p>
Excellent communication and motivational interviewing skills to educate and empower members.</p></li><li><p>
Proficiency in both English and Spanish is strongly preferred.</p></li></ul></div><div><ul><li><p>
Commitment to health equity, inclusiveness, and patient-centered care.</p></li></ul></div><div><ul><li><div><p>
Basic Life Support trained.</p></div></li></ul><p></p><p><b>
Additional Information</b></p></div><div><p><b><i>
Core Competencies:</i></b></p></div><div><ul><li><p>
Clinical quality improvement and strategic gap closure.</p></li></ul></div></div><div><div><ul><li><p>
Transitions of Care coordination and post-discharge support.</p></li></ul></div><div><ul><li><p>
Member and provider engagement with motivational interviewing.</p></li></ul></div><div><ul><li><p>
Regulatory compliance and documentation accuracy.</p></li></ul></div><div><ul><li><p>
Data interpretation and actionable reporting.</p></li></ul></div><div><ul><li><p>
Cross-functional collaboration and teamwork.</p></li></ul></div><div><ul><li><p>
Time management balancing administrative and outreach duties.</p></li></ul></div><p></p><div><p><b><i>
Values &amp; Mission Alignment:</i></b></p></div><div><ul><li><p>
Demonstrate integrity, respect, and empathy in all interactions.</p></li></ul></div><div><ul><li><p>
Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.</p></li></ul></div><div><ul><li><p>
Champion continuous learning, innovation, and professional growth.</p></li></ul></div><p></p><div><p><b><i>
Work Information:</i></b></p></div><div><p>
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.</p></div><div><ul><li><p><b>
Workstyle: Clinic-based, in-center 5 days per week</b><b>.</b></p></li></ul></div><div><ul><li><p><b>
Location:</b> Must reside in designated market area, in reasonable commutable distance to assigned clinic(s).</p></li></ul></div><div><ul><li><p><b>
Hours: </b>Monday&ndash;Friday, 8:00 AM&ndash;5:00 PM; additional time may be required.</p></li></ul></div><p></p><div><p><b><br>
TB Statement</b>:</p></div><div><p>
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.</p></div><p></p><div><p><b><br>
Driving Statement</b>:</p></div></div><div><p>
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.</p></div><p></p><p><b>
Scheduled Weekly Hours</b></p><p></p>
40<p></p><p><b>
Pay Range</b></p>
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.<br>
<p></p>
$71,100 - $97,800 per year<br>
<p></p>
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.<p></p><p><b>
Description of Benefits</b></p>
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) 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.<p></p><h1 class="jobSectionHeader"><b><br>
About Us</b><br>
</h1>
About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient&rsquo;s well-being.<p></p>
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.<p><br>
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<b>Equal Opportunity Employer</b></p><p></p><p>
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.</p></div>

Clinical Care Nurse (RN)

URBAN HEALTH PLAN, INC.

<div>
 <strong>
  Job Description
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 </strong>
 <strong>
  Position Summary:
  <br/>
  <br/>
 </strong>
 The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care.
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 The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients.
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 <br/>
 This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care.
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 <br/>
 As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift.
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 <strong>
  Minimum Qualifications
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 </strong>
 <ul>
  <li>
   Associates or Bachelors in Nursing is required.
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  <li>
   NYS Licensed Registered Nurse is required.
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   Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting.
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   Bilingual Spanish/English is required.
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   Strong care coordination and patient communication skills
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   Knowledge of hospital discharge processes and transitional care management
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   Ability to identify clinical and social determinants of health impacting care
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  <li>
   Proficiency in electronic health records and care documentation
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  <li>
   Ability to work collaboratively across multidisciplinary teams
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   <br/>
  </li>
 </ul>
 <strong>
  Key Duties
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 </strong>
 <strong>
  Transitional Care Management &amp; Patient Follow-Up
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 </strong>
 <ul>
  <li>
   Conduct outreach to patients following hospital or emergency department discharge
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  <li>
   Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
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  <li>
   Ensure patients receive timely follow-up appointments with primary care providers or specialists
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   Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
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   Perform medication reconciliation and assess for medication adherence and safety concerns
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  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
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   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
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   <br/>
  </li>
 </ul>
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  Care Coordination &amp; Continuity of Care
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 </strong>
 <ul>
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   Coordinate care between hospital systems, primary care providers, specialists, and community resources.
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   Review discharge summaries and hospital documentation to ensure appropriate follow-up care
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   Facilitate referrals, diagnostic testing, and specialty appointments as needed
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  <li>
   Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions
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  </li>
 </ul>
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  High-Risk Patient Management
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 </strong>
 <ul>
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   Identify high-risk patients based on clinical, social, and utilization risk factors
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   Provide additional monitoring and outreach for patients at risk of readmission
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   Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
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   <br/>
  </li>
 </ul>
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  Patient Education &amp; Engagement
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 </strong>
 <ul>
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   Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
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   Promote patient self-management and adherence to treatment plans
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   Encourage ongoing engagement with primary care services
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   Address health literacy and cultural considerations to improve understanding and compliance
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  </li>
 </ul>
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  Data Documentation &amp; Reporting
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   Document patient encounters and care coordination activities in the EHR
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   Track outreach efforts, successful contacts, and follow-up outcomes
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   Support reporting for Transitional Care Management (TCM) billing and quality measures
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   Contribute to organizational reporting related to readmission reduction and care continuity
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  </li>
 </ul>
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  Quality Improvement &amp; Population Health
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 <ul>
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   Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
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   Identify patterns or barriers affecting successful transitions of care
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   Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
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   Support quality improvement initiatives related to patient access and care continuity
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  </li>
 </ul>
 <strong>
  Collaboration &amp; Team Integration
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 </strong>
 <ul>
  <li>
   Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
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   Communicate patient updates and concerns to primary care teams in a timely manner
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  <li>
   Participate in multidisciplinary meetings focused on high-risk patient management and care planning
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   <br/>
  </li>
 </ul>
 <strong>
  Starting Compensation:
 </strong>
 Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience.
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 <strong>
  As a full time associate at Urban Health Plan, you'll enjoy:
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 </strong>
 <ul>
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   Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
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   Dental, Vision, and Prescription Coverage
  </li>
  <li>
   401(k) Retirement Savings (including 3% annual employer contribution)
  </li>
  <li>
   Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
  </li>
  <li>
   Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
  </li>
  <li>
   Entertainment Discount Programs
  </li>
  <li>
   Employee Assistant Program
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  <li>
   Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
  </li>
  <li>
   Fitness Discounts and Perks through our medical plan.
  </li>
  <li>
   $50,000 term life Insurance
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   <br/>
  </li>
 </ul>
 <strong>
  About Urban Health Plan
  <br/>
  <br/>
 </strong>
 At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do.
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 <em>
  UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.
  <br/>
  <br/>
 </em>
 Job Requirements
</div>


Care Transitions Nurse (RN)

Avir Health Group

<div>
 <strong>
  AVIR Health Group is seeking a qualified Registered Nurse (RN) to join our family!
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 </strong>
 <strong>
  $2,000 RN Sign On Bonus for Full-Time Only!
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  <br/>
 </strong>
 We are searching for a
 <strong>
  Registered Nurse (RN)
 </strong>
 who thrives in an environment where dedicated team members bring comfort, dignity and exceptional care to those that need it most. The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities of your assigned unit. This is the place where your work matters, and your growth is supported.
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 <strong>
  New grads are always welcome!
  <br/>
  <br/>
 </strong>
 <strong>
  Exciting Benefits:
  <br/>
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 </strong>
 <ul>
  <li>
   Competitive compensation.
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   401k with a match!
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   Company paid holidays and Paid Time Off (PTO) Program.
  </li>
  <li>
   Health insurance for the entire family!
  </li>
  <li>
   Scrubs on Wheels.
  </li>
  <li>
   Voluntary Benefits reviewed and provided at your one-on-one benefit meeting.
  </li>
  <li>
   Exceptional Corporate Support.
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   <br/>
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  </li>
 </ul>
 <strong>
  Qualifications:
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  <br/>
 </strong>
 <ul>
  <li>
   Valid Texas RN License.
  </li>
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   Valid CPR Certification.
  </li>
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   I.V. Certification Preferred.
  </li>
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   Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
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  </li>
 </ul>
 <strong>
  About the Company:
  <br/>
  <br/>
 </strong>
 We strive to create an environment where people feel safe, heard and understood. Our leadership teams embrace our &ldquo;Your Voice&rdquo; philosophy.
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 Avir Health Group is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.
</div>


Registered Nurse RN

Nexion Health, Inc.

8-hour shifts offered
<br><br>
(6a-2p, 2p-10p and 10p-6a)
<br><br>
<b>Rate:</b><br>
$35.00 - $36.00 (.10 per yr up to 20 yrs)
<br><br>
<b>Shift Differential:</b><br>
2p-10p / $.50
<br><br>
10p-6a / $.75
<br><br>
Nexion is a "Great Place to Work" because we provide
<br><br>
Free employee and family telehealth immediately upon hire
<br><br>
Medical / Dental / Vision Care
<br><br>
Early Pay
<br><br>
FSA / HSA / 401k
<br><br>
Scholarship for employees and dependents
<br><br>
Emergency Relief
<br><br>
<b>Requirements:</b><br>
Registered Nurse (RN) license required
<br><br>
Learn more about Nexion at nexion-health.com
<br><br>
EOE M/F/D/V

Registered Nurse (RN)

New Wages!!
<br><br>
12-hour shifts offered
<br><br>
(6am-6pm, 6pm-6am)
<br><br>
<b>Starting Rate:</b><br>
$32.50-$37.50 per hour
<br><br>
<b>Shift Differential:</b><br>
2:00pm - 10:00pm: $1.50 / hr.
<br><br>
<b>10:00pm - 6:00am: $2.00 / hr.:</b><br>
<b>Nexion is a "Great Place to Work" because we provide:</b><br>
Free employee and family telehealth immediately upon hire
<br><br>
Medical / Dental / Vision Care
<br><br>
Early Pay
<br><br>
FSA / HSA / 401k
<br><br>
Scholarship for employees and dependents
<br><br>
Emergency Relief
<br><br>
<b>Requirements:</b><br>
Registered Nurse (RN) license required
<br><br>
Learn more about Nexion at nexion-health.com
<br><br>
EOE M/F/D/V

12-hour shifts offered
<br><br>
(6a-6p and 6p-6a)
<br><br>
<b>Rate:</b><br>
$35.50 - $37.50 depending on experience
<br><br>
NOW OFFERING A $7,500.00 SIGN ON BONUS FOR FT LICENSED NURSES!
<br><br>
Effective 5/8/26
<br><br>
Nexion is a "Great Place to Work" because we provide
<br><br>
Free employee and family telehealth immediately upon hire
<br><br>
Medical / Dental / Vision Care
<br><br>
Early Pay
<br><br>
FSA / HSA / 401k
<br><br>
Scholarship for employees and dependents
<br><br>
Emergency Relief
<br><br>
<b>Requirements:</b><br>
Registered Nurse (RN) license required
<br><br>
Learn more about Nexion at nexion-health.com
<br><br>
EOE M/F/D/V

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