Alignment Health is seeking a remote bilingual Spanish telephonic RN case manager (California RN License Required) to join the outpatient case management team. 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.
Schedule:
Monday - Friday, 8:00 AM - 5:00 PM Pacific Time
General Duties / Responsibilities1. 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' clinical case management experience; or any combination of education and experience, which would provide an equivalent background.
Education:• Required: Bachelor's degree in Nursing.
Specialized Skills:• Required:
- Able 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.
Preferred:
- Bilingual English and Spanish, Vietnamese, or Chinese (Mandarin)
Licensure:Required:
- Current, unrestricted RN license in California (Non-Compact)
- Willing to obtain RN License in NV (Non-Compact) and AZ, NC, TX (Compact)
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: $85,696.00 - $128,543.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
