• Become a part of our caring community
• The RN Care Navigator (Care Coach) assesses and evaluates member's needs and requirements to achieve and maintain optimal wellness state by guiding members and families toward and facilitate interaction with resources appropriate for the care and wellbeing of members.

You will work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. You will report to the Associate Director, Clinical Strategy & Program Development. You will employ a variety of strategies, and techniques to manage a member's physical, environmental, and psycho-social health issues. You will resolve barriers that hinder care. You will ensure the patient is progressing towards desired outcomes by managing patient care through assessments and evaluations and may create member care plans. You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas. You will make decisions regarding own work methods that require minimal direction and receive guidance where needed.

• Use your skills to make an impact

• Responsibilities:

• + Conduct Transitions of Care Management for a subset of the patient population, including hospital, observation, and post-acute care follow-up.

+ Complete post-discharge outreach and assessment, including review of discharge needs, medication understanding, PCP follow-up status, symptoms, barriers, and support needs. + Support coordination of PCP follow-up appointments and oversee discharge instructions and PCP-established next steps. + Provide assessment guidance and supportive consultation to other team members, handling escalated complex cases within RN scope of practice. + Develop a holistic view of patient needs related to Social Determinants of Health. + Identify existing barriers to engagement with necessary resources and supports. + Provide education around maintenance of chronic health conditions, medication understanding, symptom monitoring, available behavioral care options, and social support resources. + Be a liaison between the patient, caregiver, direct care providers, practice contacts, and interdisciplinary team members to support navigation of internal and external systems. + Support patients' self-determination and motivate patients to meet the health goals they have identified. + Refer patients to necessary services and supports across the interdisciplinary team and community resource network. + Participate in interdisciplinary care team or provider/practice touchpoints when indicated to support transition-of-care coordination. + Support the patient's family and caregiver support systems and participate in patient/family discussions when needed and appropriate in a virtual setting. + Maintain patient confidentiality following HIPAA. + Document patient encounters and outreach activity in the designated medical record or documentation system promptly. + Follow general policies related to fire safety, infection control, attendance, and remote work expectations.

• Required Qualifications:

• + Registered Nurse (RN license).

+ 4+ years of experience working in human services, care coordination, care management, case management, or transitions of care. + Work in a fully remote/work-at-home environment using electronic documentation and approved systems. Remote work requires a private, secure workspace appropriate for confidential patient communication and HIPAA-compliant documentation. + Advanced clinical experience. + Flexibility to transition and adjust in an evolving role. + Compassion and desire to advocate for patient needs. + Ability for confidentiality and protect PHI in a remote work setting. + Can work in the Eastern Time Zone.

• Preferred Qualifications:

• + Experience working in care/case management, transitions of care, or post-discharge patient support.

+ Prior value-based care experience and experience working with complex senior populations. + Experience working within interdisciplinary teams and with PCP practice partners. + Experience providing patient education related to chronic condition management, medications, discharge instructions, and follow-up coordination. + Bilingual in English and Spanish or Creole with the ability to speak, read, and write in both languages without limitations or assistance. + Prefer residence in the Treasure Coast, FL area. \#LI-CM1 Work at

Home Requirements:

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member

PHI / HIPAA

information.

Travel:

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

• Scheduled Weekly Hours
• 40 •Pay Range•The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting.

The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

• Description of Benefits
• Humana, Inc.

and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

• About us

•

About Conviva Senior Primary Care:

Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana's Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (

NYSE:

HUM). Learn more about what we offer at CenterWell.com. ​

• Equal Opportunity Employer
• It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.

It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources