population health nurse

Hope Christian Health Center

<div>Description:
<p>
JOB SUMMARY: The Care Manager plays a vital role in delivering comprehensive, patient-centered care within an integrated health team at a Federally Qualified Health Center (FQHC). This position supports patients with complex medical, behavioral, and social needs by coordinating services, promoting health education, and facilitating access to appropriate care. The Care Manager works collaboratively with primary care providers, behavioral health providers, community health workers, and other team members to ensure high-quality, culturally competent, and equitable care.</p><p>
DUTIES AND RESPONSIBILITIES:</p><p>
Care Manager Duties:</p><p>
Care Coordination</p><ul><li>
Develop, implement, and monitor individualized care plans in collaboration with patients and the care team.</li><li>
Coordinate care transitions, including hospital discharges, specialty referrals, and community resource connections.</li><li>
Provide care through in-person visits, telephone, and telemedicine to ensure continuity.</li><li>
Proactively conduct outreach to patients who may benefit from services, introducing available programs and supports.</li><li>
Facilitate communication between patients, families, and interdisciplinary team members.</li></ul><p>
Patient Education and Advocacy</p><ul><li>
Deliver health education and coaching to support chronic disease management and preventive care.</li><li>
Advocate for patients and collaborate with community health workers to address social determinants of health.</li><li>
Assist in issuing medical equipment and supplies, ensuring proper documentation and follow-up.</li></ul><p>
Data and Quality Improvement</p><ul><li>
Document care management activities and track patient outcomes in the electronic health record (EHR).</li><li>
Partner with the Population Health Manager to analyze reports related to patient outcomes, care gaps, and required data metrics.</li><li>
Participate in quality improvement initiatives and population health strategies.</li><li>
Contribute to the development and refinement of care coordination workflows and reporting tools.</li></ul><p>
Other Duties:</p><ul><li>
Promotes and demonstrates Hope values of: Gospel motivation, Prayer, Excellence, Stewardship, Patience, Thankfulness, Humility, Service, Dignity through Relationship and Hospitality and Joy</li><li>
Primarily onsite in a clinical setting with occasional community outreach or home visits.</li><li>
May require flexible hours to meet patient needs.</li><li>
Complies with HIPAA and protects patient information.</li><li>
The Care Manager ensures compliance with all 19 Health Resources and Services Administration (HRSA) Health Center Program Requirements.</li><li>
The Care Manager is also expected to actively participate in and support quality improvement activities and the clinical practice team efforts emphasizing the importance of the individual patient and putting the patient&rsquo;s needs first.</li><li>
Other duties as assigned.</li></ul>
Requirements:
<p>
QUALIFICATIONS:</p><ul><li>
Registered Nurse (RN) with a current state license in Nevada - required</li><li>
Valid AHA Certified Basic Life Support (BLS) certification- required</li><li>
Bilingual in Spanish (depending on patient population) - preferred</li><li>
Minimum of 2 years of clinical nursing experience, preferably in primary care, community health, or care management - preferred</li><li>
Experience working in an integrated care setting or with underserved populations - preferred</li><li>
Proficiency in EHR systems and care coordination platforms, and data management.</li><li>
Experience with data reporting and population health tools preferred.</li></ul><p>
Education:</p><ul><li>
Bachelor&rsquo;s degree in Nursing - required</li></ul><p>
KEY COMPETENCIES FOR SUCCESS:</p><ul><li>
Faith to believe that Hope is a ministry of God, exemplifying the love of Christ, and held and directed by the Holy Spirit.</li><li>
Ability to operate general office machinery (computers, calculators, copy/fax machine, telephones, etc.)</li><li>
Excellent communication skills, both written and verbal.</li><li>
Demonstrated passion for community health care.</li><li>
Proven leadership, teambuilding, and organizational skills.</li><li>
Proven ability to maintain integrity in a fast paced and high-demand environment.</li><li>
Proven ability to manage performance goals.</li><li>
Ability to interact with people from all ethnic backgrounds, ages, and lifestyles; ability to understand and respond appropriately, effectively, and sensitively to special populations.</li></ul><p>
TYPICAL PHYSICAL DEMANDS:</p><p>
Occasional standing, walking, lifting, reaching, kneeling, bending, stooping, pushing, pulling, and lifting and/or moving up to 25 pounds. Frequent sitting. Manual dexterity. Proficient reading, eyesight, and vision for close work. Ability to communicate by speaking and hearing in person or on the phone. Ability to travel to various locations.</p></div>

Care Manager

Conviva Senior Primary Care

<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.
<br>
<br>
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>
<b>
</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><li><p>
Bilingual in English and Spanish with full professional proficiency.</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></ul></div><div><ul><li><p>
Commitment to health equity, inclusiveness, and patient-centered care.</p></li></ul></div><div><ul><li><p>
Basic Life Support trained.</p></li></ul></div><p></p><div><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 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&rsquo;s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva&rsquo;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 &ndash; addressing the social, emotional, behavioral and financial needs that can impact our patients' 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>
<br>
<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)

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.
<br>
<br>
CenterWell/Conviva clinic locations may be available in the following areas: CW Oviedo Main, CW Longwood New<br>
<br>
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>
Job Description</div></div><div><div><div><div><div><div><div><div><div><p><b>
Role Scope</b>
</p><ul><li><p>Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients.</p></li><li><p>
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.
</p></li><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><p></p><p><b>Duties and Responsibilities</b>:
</p><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><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><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><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><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><li><p>Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
</p></li><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><li><p>Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.
</p></li><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><li><p>Support clinic operations through provider collaboration, care coordination, and community education initiatives.
</p></li><li><p>Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.
</p></li><li><p>Maintain patient confidentiality in accordance with HIPAA.
</p></li><li><p>Document patient encounters accurately and timely in the indicated platform (e.g., medical record).
</p></li><li><p>Follow organizational policies related to safety, infection control, and attendance.
</p></li><li><p>Perform other duties as assigned.</p></li></ul></div></div></div></div></div></div></div></div></div><h1 class="jobSectionHeader"><b><br>
Use your skills to make an impact
</b><br>
</h1><div><b>Required Qualifications:</b></div><div><div><div><div><div><div><div><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><li><p>
Active, unrestricted RN license in Florida.</p></li><li><p>
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.</p></li><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><li><p>
Willing and able to complete and maintain Basic Life Support training.
</p></li></ul><p></p><p><b>Preferred Qualifications:</b></p><ul><li><p>
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.</p></li><li><p>
Experience with Transitions of Care, hospital discharge or ER follow up programs.</p></li><li><p>
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.</p></li><li><p>
Excellent communication and motivational interviewing skills to educate and empower members.</p></li><li><p>
Commitment to health equity, inclusiveness, and patient-centered care.</p></li><li><p>
Bilingual in English and Spanish with full professional proficiency. (strongly preferred)</p></li><li><p>
Basic Life Support trained.</p></li></ul><p></p><p><b>
Additional Information</b></p><p><b><i>
Core Competencies:</i></b></p><ul><li><p>
Clinical quality improvement and strategic gap closure.</p></li><li><p>
Transitions of Care coordination and post-discharge support.</p></li><li><p>
Member and provider engagement with motivational interviewing.</p></li><li><p>
Regulatory compliance and documentation accuracy.</p></li><li><p>
Data interpretation and actionable reporting.</p></li><li><p>
Cross-functional collaboration and teamwork.</p></li><li><p>
Time management balancing administrative and outreach duties.</p></li></ul><p></p><p><b><i>
Values &amp; Mission Alignment:</i></b></p><ul><li><p>
Demonstrate integrity, respect, and empathy in all interactions.</p></li><li><p>
Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.</p></li><li><p>
Champion continuous learning, innovation, and professional growth.</p></li></ul><p></p><p><b><i>
Work Information:</i></b></p><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><ul><li><p><b>
Workstyle: Clinic-based, in-center 5 days per week.</b></p></li><li><p><b>
Location:</b> Must reside in designated market area, in reasonable commutable distance to assigned clinic(s).</p></li><li><p><b>
Hours: </b>Monday&ndash;Friday, 8:00 AM&ndash;5:00 PM; additional time may be required.</p></li></ul><p></p><p><b>
TB Statement</b>:</p><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><p></p><p><b>
Driving Statement</b>:</p><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></div></div></div></div></div></div></div></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>
<br>
<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 Registered Nurse (RN)

<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.<br>
<br>
Conviva clinic locations may be available in the following areas: Tampa, FL: Hanley and Hudson<br>
<br>
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><p><b>
Role Scope</b></p><ul><li>
Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients.</li><li>
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.</li><li>
Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.</li></ul><p></p><p><b>
Duties and Responsibilities</b>:</p><p></p><ul><li>
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.</li><li>
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.</li><li>
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.</li><li>
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.</li><li>
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.</li><li>
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.</li><li>
Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.</li><li>
Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.</li><li>
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.</li><li>
Support clinic operations through provider collaboration, care coordination, and community education initiatives.</li><li>
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.</li><li>
Maintain patient confidentiality in accordance with HIPAA.</li><li>
Document patient encounters accurately and timely in the indicated platform (e.g., medical record).</li><li>
Follow organizational policies related to safety, infection control, and attendance.</li><li>
Perform other duties as assigned.</li></ul><h1 class="jobSectionHeader"><br>
<b>
Use your skills to make an impact</b><br>
<b>
</b></h1><p><b>Required Qualifications:</b></p><p></p><ul><li>
Must meet one of the following requirements: Associate's degree in nursing (ADN) or Bachelor's degree in nursing (BSN).</li><li>
Active, unrestricted RN license (state specific as applicable).</li><li>
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.</li><li>
Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud &ndash; per your prior employer's population health tools), and Microsoft Office Suite.</li><li>
Willing and able to complete and maintain Basic Life Support training.</li></ul><p></p><p><b>
Preferred Qualifications:</b></p><p></p><ul><li>
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.</li><li>
Experience with Transitions of Care, hospital discharge or ER follow up programs.</li><li>
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.</li><li>
Excellent communication and motivational interviewing skills to educate and empower members.</li><li>
Commitment to health equity, inclusiveness, and patient-centered care.</li><li>
Bilingual in English and Spanish with full professional proficiency.</li><li>
Basic Life Support trained.</li></ul><p></p><p><b>
Additional Information:</b></p><p></p><p><b><i>
Core Competencies:</i></b></p><ul><li>
Clinical quality improvement and strategic gap closure.</li><li>
Transitions of Care coordination and post-discharge support.</li><li>
Member and provider engagement with motivational interviewing.</li><li>
Regulatory compliance and documentation accuracy.</li><li>
Data interpretation and actionable reporting.</li><li>
Cross-functional collaboration and teamwork.</li><li>
Time management balancing administrative and outreach duties.</li></ul><p></p><p><b><i>
Values &amp; Mission Alignment:</i></b></p><ul><li>
Demonstrate integrity, respect, and empathy in all interactions.</li><li>
Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.</li><li>
Champion continuous learning, innovation, and professional growth.</li></ul><p></p><p><b><i>
Work Information:</i></b></p><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><ul><li><b>
Workstyle: Clinic-based, in-center 5 days per week.</b></li><li><b>
Location:</b> Must reside in designated market area, in reasonable commutable distance to assigned clinic(s).</li><li><b>
Hours: </b>Monday&ndash;Friday, 8:00 AM&ndash;5:00 PM; additional time may be required.</li></ul><p></p><p><b>
TB Statement</b>:</p><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><p></p><p><b>
Driving Statement</b>:</p><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><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 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&rsquo;s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva&rsquo;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 &ndash; addressing the social, emotional, behavioral and financial needs that can impact our patients' 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>
<br>
<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) - Tampa

<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.
<br>
<br>
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>
<b>
</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><p></p><ul><li><p>
Bilingual in English and Spanish with full professional proficiency.</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></ul></div><div><ul><li><p>
Commitment to health equity, inclusiveness, and patient-centered care.</p></li></ul></div><div></div><div><ul><li><p>
Basic Life Support trained.</p></li></ul></div><p></p><div><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><p></p><p>
#LI-ED1</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 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&rsquo;s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva&rsquo;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 &ndash; addressing the social, emotional, behavioral and financial needs that can impact our patients' 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>
<br>
<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>

Bilingual Clinical Care Nurse (RN)

UC Health

<div><p><b>Ambulatory Telehealth RN, Neurology, Full Time, First Shift</b></p><p>
The Ambulatory Telehealth RN is responsible for providing comprehensive nursing care through remote telehealth services. This position involves patient assessment, triage, care coordination, patient education, population health management, and patient navigation in UC Health ambulatory clinics using telehealth technology. The Ambulatory Telehealth RN plays an integral role in the management of patients&rsquo; care and is expected to collaborate with UC Health providers and staff to ensure high-quality patient centered care.</p><div><b>
PATIENT POPULATION - (CLINICAL ONLY):</b><br>
<ul><li>Engages in population appropriate communication.</li><li>Has knowledge of growth and development milestones and tasks.</li><li>Gives clear instructions to patients/family regarding treatment.</li><li>Involves family/guardian in the assessment, initial treatment and continuing care of the patient.</li><li>Identifies any physical limitations of the patient and deploys intervention when necessary.</li><li>Recognizes and responds appropriately to patients/families with behavioral health problems.</li><li>Interprets population related data and plans care appropriately.</li><li>Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely.</li><li>Recognizes and responds to signs/symptoms of abuse or neglect.</li></ul></div><div><b>
PATIENT ASSESSMENT &amp; INTERVENTIONS:</b><br>
<ul><li>Conduct initial patient assessments via telehealth platforms.</li><li>Utilizes the nursing process (assess, diagnose, plan, implement, and evaluate) to address patients&rsquo; concerns completely.</li><li>Monitor patients&rsquo; conditions and progress remotely.</li><li>Manages inbound calls from patients, families, and UC Health care team members.</li><li>Adheres to established policies and procedures for the nurse triage and/or escalation process.</li><li>Initiate and implement individualized patient care plans in collaboration with other healthcare providers based on clinical assessments, disease process, and patient&rsquo;s identified psychosocial needs.</li><li>Maintains and expands knowledge of nurse telehealth processes and clinical expertise regarding population served</li><li>Able to recognize abnormal labs or results and collaborate with care team when changes are identified.</li><li>Anticipate changing needs of patients and families based on care plan and act proactively to reduce delays in care, reduce financial toxicity, and increasing patient satisfaction.</li><li>Coordinate care plans in collaboration with healthcare providers.</li><li>Facilitate referrals to specialists and other ancillary health services.</li></ul></div><div><b>
PATIENT EDUCATION:</b><br>
<ul><li>Educate patients and their families about health conditions, treatment plans, medications, and self-care techniques.</li><li>Offer guidance on managing chronic conditions and preventative care.</li><li>Reassess for understanding and re-educate as needed.</li><li>Supports patients and families in understanding telehealth processes</li><li>Documents outcomes of patient/family/designee teaching and response appropriately.</li></ul></div><div><b>
DOCUMENTATION &amp; COMMUNICATION:</b><br>
<ul><li>Maintain accurate, timely, and professional documentation of patient interactions utilizing electronic platforms and according to system and departmental protocols.</li><li>Ensure compliance with regulatory and organizational standards; maintains confidentiality of information and data security.</li><li>Utilizing MIDAS effectively to report system patient safety concerns.</li><li>Communicate effectively with patients and healthcare providers regarding test results, treatment plans, and follow-up care.</li><li>Address patient concerns and provide support and guidance to address questions and concerns via remote platforms.</li><li>Evaluate needs and escalate patient issues to appropriate team members utilizing technological avenues.</li><li>Utilizing all technology platforms, collaborates with social workers, dietitians, and other healthcare professionals to address the needs of patients.</li><li>Documents plan of care reflective of collaborative practice with other health care team members.</li><li>Follows up with patients as promised and uses &ldquo;closed loop&rdquo; communication strategies with patients and healthcare team members.</li></ul></div><div><b>
TECHNOLOGY UTILIZATION:</b><br>
<ul><li>Utilizes Epic, Microsoft Office Applications, telephone software and hardware throughout the shift to ensure proper execution of responsibilities</li><li>Proficient in the use of multiple computer and telephone applications to perform job responsibilities</li><li>Use telehealth technology to conduct video or phone consultations</li><li>Troubleshoot technical issues with patients and provide basic technical support when necessary.</li><li>Stay updated on new telehealth technologies and best practices.</li></ul></div><div><b>
LEADERSHIP &amp; PROFESSIONAL DEVELOPMENT:</b><br>
<ul><li>Serves on nursing and hospital-wide and unit-based committees that influence the delivery of patient care as needed and when relevant to telehealth nursing</li><li>Assists with developing and revising policies and procedures for telehealth nursing practice.</li><li>Assist with implementing process improvements for telehealth nursing teams</li><li>Works collaboratively on performance improvement system wide as needed.</li><li>Demonstrates the telehealth&rsquo;s nurse role as a member of the healthcare team and promotes accountability, responsibility, and commitment regarding patient care standards.</li><li>Orientation and other education programs as assigned.</li><li>Remains current in research to area of clinical nursing practices</li><li>Participates and contributes to staff meetings</li></ul></div><p><b>
OTHER DUTIES AS ASSIGNED</b></p><ul><li>
Minimum Required: Associate's Degree - Nursing. Preferred: Bachelor's Degree - Nursing. |</li></ul><p><b>
LICENSE &amp; CERTIFICATION</b>: Current Registered Nurse (RN) license in the state of Ohio.</p><ul><li>
Basic Life Support (BLS) certification preferred.</li><li>
Minimum Required: 2 years nursing experience, preferred if experience includes a combination of acute or long-term care nursing experience and ambulatory or outpatient nursing experience. Previous experience in telehealth preferred.</li></ul></div><p></p>

Ambulatory Telehealth Registered Nurse (RN), Neurology, Full Time, First Shift

TEEMA Group

<div><p><b>Position Overview:</b></p><p>
The Nurse Practitioner will provide direct and indirect care to patients. Working under the direct supervision of the Medical Director/PCP, this role involves managing complex clinical situations, performing health assessments, and coordinating patient care.</p><p><b>
Responsibilities</b>:</p><ul><li><p>
Conduct health histories, physical exams, and patient teaching; order, interpret, and follow up on lab tests and results.</p></li><li><p>
Perform selected procedures and document care in the electronic medical record (EMR); initiate emergency measures as needed.</p></li><li><p>
Manage medication orders and diagnostic studies/treatments within attending physician-approved protocols.</p></li><li><p>
Assess, initiate, and coordinate patient care daily under the supervision of the attending physician.</p></li><li><p>
Refer patients to other physicians and specialists with staff PCP approval.</p></li><li><p>
Act as a liaison with healthcare professionals, providing education, communication, and support for staff, patients, and families.</p></li><li><p>
Participate in the provider call schedule and attend staff meetings.</p></li><li><p>
Assist the interdisciplinary team (IDT) in formulating a plan for the coordination of 24-hour care.</p></li><li><p>
Document patient changes in the medical record and communicate these changes to team members.</p></li><li><p>
Evaluate and treat patients in various settings, including homes, assisted living facilities, nursing homes, and hospitals.</p></li><li><p>
Precept medical students and residents during their clinic rotation.</p></li><li><p>
Encourage patients to have Advanced Directives and provide education as needed; discuss Do Not Resuscitate (DNR) options and complete necessary documentation in collaboration with a physician.</p></li><li><p>
Other duties as assigned</p></li></ul><p><b>
Qualifications</b>:</p><ul><li><p>
Master&rsquo;s degree in clinical nursing from an accredited Nurse Practitioner program.</p></li><li><p>
3-5 years of nursing experience, with Nurse Practitioner experience preferred.</p></li><li><p>
Ability to practice within the scope of authority and meet standardized competencies as established by the state and approved by CMS.</p></li><li><p>
Experience working with a frail or elderly population preferred; training provided if necessary.</p></li><li><p>
Reliable transportation, a valid driver's license, and state-required liability auto insurance.</p></li><li><p>
Medically cleared for communicable diseases and up-to-date immunizations before engaging in direct patient contact.</p></li><li><p>
Pass a comprehensive criminal background check, including federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.</p></li></ul><p><b>
Setting</b>: Out Patient Clinic</p><p><b>
Population</b>: Geratic population</p><p><b>
Benefits:</b></p><ul><li><p>
Competitive salary and benefits package.</p></li><li><p>
Opportunity to work with a dynamic and growing organization.</p></li><li><p>
Monday - Friday NO WEEKENDS</p></li></ul><p><b>
If you're interested, please reply to this advertisement or directly email your resume to me at DSalgado@teemagroup.com or by calling/texting (949) 295-5951.</b></p><p><b>
I strive to reply within 48 hours. Looking forward to connecting with you soon. Thank you!</b></p>
#Workwolf</div>

Nurse Practitioner NP

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