Registered Nurse Care Coordinator in Arizona City, AZ

Join Our Compassionate Team and Prioritize Health Overview As a Registered Nurse Care Coordinator, you will be a pivotal member of our interdisciplinary care integration team (CIT), proactively engaging patients to enhance their overall health and access to necessary care. You will guide other team members in care coordination efforts and manage clinical escalations effectively. This position requires sensitivity to socio-economic factors affecting healthcare engagement and health outcomes. Ideal candidates will have prior experience in case management for high-risk patients and transitions of care, collaborating closely with PCP care team members such as community health workers, pharmacists, and behavioral health professionals. Duties and Responsibilities • Conduct Transitions of Care Management for patients, including hospital, observation, and post-acute care follow-ups. • Provide triage support and consultation to team members on complex cases. • Develop care plans using the 5Ms Geriatric best practice framework. • Assess patients' needs through a holistic understanding of Social Determinants of Health. • Identify barriers to healthcare engagement and connection to resources. • Educate patients on managing chronic conditions and available behavioral health options. • Act as a liaison, facilitating navigation between patients and their direct care providers. • Initiate care plans and coordinate action steps for high-risk members with the interdisciplinary team. • Encourage self-determination in patients and motivate them to achieve their health goals. • Refer patients to essential services and supports within the care team. • Assist with logistical issues like transportation, food security, benefits applications, and medication costs. • Lead CIT team meetings as necessary. • Assess and meet with patients' families and caregivers when appropriate. • Contribute to team training development and delivery. • Participate in multidisciplinary reviews for complex patient cases. • Ensure patient confidentiality is maintained in accordance with HIPAA regulations. • Document patient interactions in the medical record system promptly. • Follow policies for fire safety, infection control, and attendance. • Assist with additional responsibilities as required. Use Your Skills to Make a Difference Required Qualifications • Valid Registered Nurse (RN) license. • A minimum of 4 years of experience in human services and community resource navigation. Preferred Qualifications • Experience in care or case management. • Familiarity with value-based care and management of complex senior populations. • Effective collaboration experience within interdisciplinary teams. • Bilingual capabilities in English and Spanish or Creole, with fluency in speaking, reading, and writing. Necessary Skills/Abilities/Competencies • Advanced clinical skills. • Ability to manage multiple tasks in a fast-paced environment. • Adaptability to change in a dynamic role. • Strong organizational capabilities. • Exceptional oral and written communication skills. • Excellent interpersonal and relationship-building abilities. • Compassionate advocacy for patient needs. • Critical thinking and problem-solving skills. Working Conditions This position requires mobility; regular onsite engagement with care teams at clinics is necessary to see patients in person and collaborate effectively. Workstyle: Hybrid - a mix of in-office and remote work. Location: Must reside in the Phoenix metro area. Hours: A 40-hour work week is required, Monday through Friday from 8:00 AM to 5:00 PM, with potential for additional hours as necessary. Tuberculosis (TB) Screening: As this role involves interacting with members, participation in Humana's TB screening program is mandatory. License and Transportation Requirements: The position requires a valid state driver's license, maintenance of insurance meeting state minimums, and access to a reliable vehicle. Compensation Base pay for this full-time role ranges from $71,100 to $97,800 annually, reflecting individual qualifications and experience. Eligible for a performance-based bonus opportunity. Benefits Overview Humana provides robust benefits aimed at promoting well-being, including medical, dental, and vision plans, a 401(k) retirement plan, paid time off, short and long-term disability, life insurance, and many more opportunities for personal and family wellness. About CenterWell Senior Primary Care CenterWell Senior Primary Care delivers proactive, preventive healthcare to seniors, focusing on wellness visits, chronic condition management, and personalized patient experiences. Our dedicated care teams spend extensive time with patients, ensuring better health outcomes by addressing physical, emotional, and social health factors. About CenterWell, a Humana Company CenterWell embodies a patient-centered approach as the nation’s largest senior-focused primary care provider. We foster whole-person health by addressing comprehensive wellness factors, and we offer stability, competitive benefits, and growth opportunities for our team members. Equal Opportunity Employer Humana is committed to non-discrimination in employing individuals regardless of race, color, religion, gender, sexual orientation, identity, national origin, age, marital status, genetic information, disability, or veteran status. We actively promote equal employment opportunities. CenterWell affirms compliance with all federal civil rights laws and provides free language interpreter services.