RN Case Manager - Transition of Care (Outpatient, Bilingual Spanish) - Remote

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.Responsible for health care management and coordination within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Coordinates and monitors Alignment Healthcare member’s progress and services to ensure consistent cost-effective care that complies with Alignment policy and all state and federal regulations and guidelines. Performs duties mostly telephonically.

General Duties/Responsibilities

1. Ensures member access to services appropriate to their health needs.
2. Identifies, assesses, and manages members per established criteria.
3. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Uses independent judgment to determine appropriateness of such authorizations. Deploys internal and external resources to meet identified needs.
4. Monitors and evaluates effectiveness of the care management plan and modifies, as necessary.
5. Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners, and specialists on the development of care management treatment plans.
6. Negotiates rates of reimbursement, as applicable.
7. Assists in problem solving with providers, claims or service issues.
8. Measures the effectiveness of interventions to determine case management outcomes.
9. Participates and provides feedback in the development of utilization/care management policies and procedures.
10. Counsels and engages in personal discussions with patients and their families on available care options. Helps them to determine their appropriate and preferred course of action.

Job Requirements:

Experience:

• Required: Minimum 5 years of clinical case management experience; or any combination of education and experience, which would provide an equivalent background.

Education:

• Required: Associates or Bachelor's degree in Nursing.

• Preferred: BSN

Specialized Skills:

• Required:

• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.

• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;

• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Licensure:

• Required: Current, unrestricted RN license in the state for which you are applying

• Preferred:

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email View email address on aiapply.co.