Clinical Care RN
Savannah, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Savannah, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Savannah, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Canton, GA · On-site
$34 - $39/hr
This part-time role is ideal for a newly licensed RN interested in care management, senior care ... transitional-care assistance. HomeWell Care Services GA311 is an equal opportunity employer.
New
Quick apply
Canton, GA · On-site
$34 - $39/hr
This part-time role is ideal for a newly licensed RN interested in care management, senior care ... transitional-care assistance. HomeWell Care Services GA311 is an equal opportunity employer.
New
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care. Education * Graduate from a recognized ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care. Education * Graduate from a recognized ...
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Decatur, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
$71K - $97K/yr
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Atlanta, GA · On-site
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care. Qualifications Education * Graduate from ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care. Qualifications Education * Graduate from ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care.Qualifications Education * Graduate from ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care.Qualifications Education * Graduate from ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care.Qualifications Education * Graduate from ...
The manager will also provide Care Management services for hospital patients as appropriate to guide care facilitation, coordination, and transitions of care.Qualifications Education * Graduate from ...
Be Seen First
Thomson, GA · On-site
$14 - $24/hr
Manage transitional care for patients following hospital or facility discharge, including timely outreach and follow-up * Support medication adherence by reviewing regimens with patients, identifying ...
Quick apply
Be Seen First
Thomson, GA · On-site
$14 - $24/hr
Manage transitional care for patients following hospital or facility discharge, including timely outreach and follow-up * Support medication adherence by reviewing regimens with patients, identifying ...
Be Seen First
Thomson, GA · On-site
$14 - $24/hr
Manage transitional care for patients following hospital or facility discharge, including timely outreach and follow-up * Support medication adherence by reviewing regimens with patients, identifying ...
Quick apply
Be Seen First
Thomson, GA · On-site
$14 - $24/hr
Manage transitional care for patients following hospital or facility discharge, including timely outreach and follow-up * Support medication adherence by reviewing regimens with patients, identifying ...
$26.6K - $31.3K
19% of jobs
$33.3K is the 25th percentile. Wages below this are outliers.
$31.3K - $36K
14% of jobs
The median wage is $39.5K / yr.
$36K - $40.8K
23% of jobs
$40.8K - $45.5K
13% of jobs
$49.8K is the 75th percentile. Wages above this are outliers.
$45.5K - $50.2K
6% of jobs
$50.2K - $54.9K
6% of jobs
$54.9K - $59.6K
9% of jobs
$59.6K - $64.4K
5% of jobs
$64.4K - $69.1K
3% of jobs
$69.1K - $73.8K
1% of jobs
$73.8K - $78.5K
0% of jobs
$26.6K
$44.6K
$78.5K
A Transitional Care Management professional is responsible for coordinating and overseeing a patient's care as they move between different healthcare settings, such as from hospital to home. Daily duties often include assessing patient needs, developing individualized care plans, facilitating communication between healthcare providers and family members, and ensuring all necessary follow-up appointments and medications are in place. They also work to identify and address potential barriers to recovery, such as social or environmental factors, to prevent hospital readmissions. The role involves close collaboration with physicians, nurses, social workers, and community resources to provide comprehensive support throughout the transition process.
A Transitional Care Management (TCM) job involves coordinating care for patients as they transition from a hospital or skilled nursing facility back to their home or community setting. TCM professionals, such as nurses or care coordinators, ensure that patients receive follow-up care, medication management, and necessary support to prevent complications or hospital readmission. They communicate with healthcare providers, educate patients on their conditions, and address any barriers to recovery. The goal of TCM is to improve patient outcomes and enhance the continuity of care during this critical period.
To thrive in Transitional Care Management, you need clinical expertise in patient care coordination, discharge planning, and chronic disease management, usually supported by a healthcare degree such as nursing, social work, or a related field. Familiarity with electronic health records (EHRs), care planning software, and current transitional care guidelines is highly valued, along with certifications like CCM (Certified Case Manager) or TCM (Transitional Care Management) when available. Outstanding organization, problem-solving, and interpersonal communication are essential soft skills for building relationships with patients, families, and multidisciplinary teams. These abilities are crucial for ensuring seamless transitions, reducing readmissions, and improving patient health outcomes during vulnerable periods of care transfer.

$71K - $97K/yr
Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Re-posted 5 days ago
7.6
Based on 23 frontline employees who took The Breakroom Quiz
9th of 239 rated social care providers
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.
Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.
Duties and Responsibilities:
Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.
Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits.
Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization.
Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows.
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.
Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Support clinic operations through provider collaboration, care coordination, and community education initiatives.
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.
Maintain patient confidentiality in accordance with HIPAA.
Document patient encounters accurately and timely in the indicated platform (e.g., medical record).
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.
Required Qualifications:
Must meet one of the following requirements: Associate’s degree in nursing (ADN) or Bachelor’s degree in nursing (BSN).
Active, unrestricted RN license (state specific as applicable).
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.
Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud – per your prior employer’s population health tools), and Microsoft Office Suite.
Willing and able to complete and maintain Basic Life Support training.
Preferred Qualifications:
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.
Experience with Transitions of Care, hospital discharge or ER follow up programs.
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.
Excellent communication and motivational interviewing skills to educate and empower members.
Commitment to health equity, inclusiveness, and patient-centered care.
Bilingual in English and Spanish with full professional proficiency. (strongly preferred)
Basic Life Support trained.
Additional Information
Core Competencies:
Clinical quality improvement and strategic gap closure.
Transitions of Care coordination and post-discharge support.
Member and provider engagement with motivational interviewing.
Regulatory compliance and documentation accuracy.
Data interpretation and actionable reporting.
Cross-functional collaboration and teamwork.
Time management balancing administrative and outreach duties.
Values & Mission Alignment:
Demonstrate integrity, respect, and empathy in all interactions.
Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.
Champion continuous learning, innovation, and professional growth.
Work Information:
This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.
Workstyle: Clinic-based, in-center 5 days per week.
Location: Must reside in designated market area, in reasonable commutable distance to assigned clinic(s).
Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required.
TB Statement:
This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Driving Statement:
This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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Health care and social assistance
1,001 - 5,000 Employees
Louisville, KY, US