Complex Care Registered Nurse

Alignment Health is a forward‑thinking provider focused on serving seniors and those who need it most. Job Responsibilities Own the Member Journey and Care Coordination for High‑Acuity Members: Primary care coordinator for an assigned panel of medically complex, high‑risk Medicare Advantage members; maintain consistent engagement cadence, proactively monitor clinical status, and ensure all care activities across the pod are integrated and progressing. Build trusted relationships with members and their caregivers through regular telehealth outreach; identify changes in condition, barriers to care, and social needs requiring intervention. Manage Transitions of Care and Hospital Discharge Coordination: Own transitions for members discharging from hospitals, SNFs, and other inpatient settings; complete timely post‑discharge outreach, medication reconciliation, and follow‑up coordination to reduce avoidable readmissions. Ensure all members’ care plans are updated after transitions and that all pod team members have the clinical context needed to support the member. Conduct medication reconciliations for assigned members; review medication lists for accuracy, appropriateness, adherence, identify potential interactions, and escalation to the APC when needed. Monitor for symptom changes, lab values, and care gap alerts; facilitate outreach and coordinate responses across the pod when abnormal findings require action. Serve as the first clinical escalation point within the pod; triage member clinical concerns, assess urgency, and route to PCP, APC, or RMO for provider‑level intervention when needed. Maintain situational awareness of member health status during virtual visits and between encounters; proactively flag emerging clinical risks before they require emergency intervention. Coordinate seamlessly with the member’s PCP, APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure each member’s care is cohesive and accountable across every pod role. Serve as the central communication point for caregivers; ensure updates, care plan changes, and clinical concerns are shared promptly and accurately with all pod members and external care partners. Participate in care gap closure activities; facilitate outreach for abnormal lab values, overdue preventive services, and HEDIS measure gaps in coordination with the Care Coordinator and APC. Support the pod’s quality performance targets by ensuring members receive timely follow‑up, preventive care reminders, and education that closes documented care gaps. Proactively manage members with chronic conditions (e.g., heart failure, COPD, diabetes, CKD, and other high‑risk comorbidities) through ongoing monitoring and structured care pathway oversight; ensure care aligns with evidence‑based, guideline‑directed medical therapy (GDMT) and best‑practice protocols. Identify changes in clinical status, adherence gaps, and emerging risks through regular outreach and review of clinical indicators; partner with member PCPs, APCs, and the pod to optimize treatment plans. Reinforce chronic disease education with members and caregivers, including medication adherence, symptom management, lifestyle modifications, and escalation triggers. Maintain updated care plans and coordinate across disciplines to support stabilization, prevent exacerbations, and reduce avoidable utilization while advancing quality and outcome goals. Document all clinical interactions accurately and timely in Athena; maintain accurate, complete, and timely documentation of all member interactions, care coordination activities, medication reconciliations, escalations, and care plan updates within established timeframes; ensure documentation supports HCC coding accuracy, care continuity, and compliance with CMS and organizational standards. Job Requirements Experience (Required) – Minimum 3 years of clinical RN experience with direct patient care in complex care, care management, transitions of care, case management, palliative care/hospice, acute care, or a related clinical setting. Demonstrated experience managing medically complex, high‑risk patient populations – including chronic disease management, medication reconciliation, and care transition coordination. Prior experience in a Medicare Advantage, managed care, home‑based care, or value‑based care environment with working knowledge of HEDIS, HCC coding, and care gap management. Experience working in a telehealth or virtual care delivery model – proficiency in virtual member engagement and remote clinical monitoring. Demonstrated ability to coordinate care across multiple disciplines and communicate effectively with clinical and non‑clinical team members. Preferred – Experience with Athena EMR and TalkDesk or equivalent virtual engagement platform; background in population health, care management programs, or complex case management for Medicare populations. Education Associate Degree in Nursing (ADN) – Bachelor of Science in Nursing (BSN) strongly preferred. Active, unrestricted Registered Nurse (RN) license in applicable state(s); multi‑state licensure preferred for the fully virtual, multi‑market model. Current BLS certification preferred. BSN or higher from an accredited nursing program (preferred). Case Management Certification (CCM) or equivalent care management credential (preferred). Training Demonstrated proficiency with telehealth delivery platforms. Working knowledge of Medicare Advantage benefits, care coordination protocols, and transitions of care standards. Preferred: formal training in motivational interviewing, health coaching, or complex care management; HEDIS documentation and quality measure training; transitions of care certification or equivalent training. Specialized Skills Complex Care Coordination and Member Journey Management (Advanced) – Ability to own and manage the full care journey for high‑acuity Medicare Advantage members; maintain consistent engagement, coordinate across disciplines, and proactively address clinical and social needs. Transitions of Care and Medication Reconciliation (Advanced) – Expert proficiency in post‑discharge care coordination; medication reconciliation, care plan updates, follow‑up outreach, and cross‑disciplinary communication that reduces readmission risk. Clinical Assessment and Escalation Judgment (Advanced) – Assess member clinical status through virtual encounters; identify changes in condition, triage urgency, and escalation to the APC or RMO with appropriate clinical context. Telehealth and Virtual Member Engagement (Advanced) – Deliver clinical care coordination entirely through virtual channels; conduct effective telehealth encounters, build member trust remotely, and maintain engagement cadence for a complex, high‑risk population. Athena EMR and Clinical Documentation (Advanced) – Advanced proficiency ensuring all care coordination activities, medication reconciliations, escalations, and care plan changes are documented accurately, completely, and within required timeframes to support HCC coding and compliance. Cross‑Disciplinary Communication and Pod Collaboration (Advanced) – Serve as central coordination hub; communicate clearly and proactively with APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure cohesive, accountable care delivery for every assigned member. HEDIS and Quality Measure Awareness (Intermediate) – Working knowledge of HEDIS measures relevant to the Medicare Advantage population; ability to identify and facilitate care gap closure activities in coordination with the APC and Care Coordinator. Essential Physical Functions While performing the duties of this job, the employee is regularly required to talk or hear, 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 include close vision and ability to adjust focus. Pay Range $85,696.00 – $128,543.00 (may vary by location, education, experience, and responsibilities). Equal Opportunity 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. #J-18808-Ljbffr E2E Alignment Healthcare USA, LLC