Remote Complex Care Registered Nurse - California Residents ; California RN License

Alignment Health is a forward‑thinking provider focused on serving seniors and those who need it most.

• 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 time frames; ensure documentation supports HCC coding accuracy, care continuity, and…