Role Scope

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

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

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

Duties and Responsibilities:

• Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.

• Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits.

• Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.

• Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization.

• Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows.

• Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.

• Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.

• Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.

• Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.

• Support clinic operations through provider collaboration, care coordination, and community education initiatives.

• Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.

• Maintain patient confidentiality in accordance with HIPAA.

Required Qualifications:

• Must meet one of the following requirements: Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN).

• Active, unrestricted RN license (state specific as applicable).

• 3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.

• Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer’s population health tools), and Microsoft Office Suite.

• Willing and able to complete and maintain Basic Life Support training.

Preferred Qualifications:

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

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

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

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

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

• Basic Life Support trained.

Additional Information

Core Competencies:

• Clinical quality improvement and strategic gap closure.

• Transitions of Care coordination and post-discharge support.

• Member and provider engagement with motivational interviewing.

• Regulatory compliance and documentation accuracy.

• Data interpretation and actionable reporting.

• Cross-functional collaboration and teamwork.

• Time management balancing administrative and outreach duties.

Values & Mission Alignment:

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

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

• Champion continuous learning, innovation, and professional growth.

Work Information:

This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.

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

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

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

TB Statement:

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

Driving Statement: