Case Manager (ACO) CA RN License Required - 100% Remote at Alignment Healthcare USA, LLC in Los Angeles, California

Job Description:

Alignment Health Accountable Care Organization (ACO) is a group of clinicians and other health care providers brought together to provide coordinated care to Medicare beneficiaries. As per the Centers for Medicare & Medicaid Services (CMS), the purpose of the model is to improve the quality of care for people with Medicare through better coordination and reaching and connecting health care providers with beneficiaries, including those who are underserved, a priority for achieving equitable outcomes through high quality, affordable, person-centered care. As part of the Alignment Health team, your role will primarily be to support the ACO beneficiaries, but may also include other Alignment Health patients.

Position Summary:

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 (May include but are not limited to):

• Ensures member access to services appropriate to their health needs.

• Supports members through transitions of care and provides health education and care coordination to improve health outcomes.

• Identifies, assesses, and manages members per established criteria.

• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Deploys internal and external resources to meet identified needs.

• Monitors and evaluates effectiveness of the care management plan and modifies, as necessary.

• Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners, and specialists on the development of care management treatment plans.

• Assists in problem solving with providers, claims or service issues.

• Measures the effectiveness of interventions to determine case management outcomes.

• 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.

Supervisory responsibilities:

N/A

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Minimum Experience:

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

2. Education/Licensure:

a. Requires a BA/BS in a health-related field (preferred)

b. Current, unrestricted CA RN license in the state for which you are applying

c. Ability to obtain expanded licensure to support new/existing markets as requested

3. Other:

a. N/A

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.