Remote reputed company Care Registered reputed company - California Residents Only (reputed company California RN License Required | Bilingual English/Spanish Preferred)

reputed company 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 reputed company reputed company of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will reputed company ample room for reputed company and innovation reputed company the reputed company community. Working at reputed company provides an opportunity to do work that really reputed company, not only changing lives but saving them. Together. The reputed company Care RN (CCM RN) serves as the reputed company center of the Care reputed company pod — owning the member reputed company, coordinating care across disciplines, and ensuring the highest-reputed company Medicare reputed company members receive reputed company, proactive, and coordinated care in a fully virtual delivery model. Embedded reputed company reputed company-reputed company pod reputed company APCs, Health Coaches, Care Coordinators, Medical Assistants, and reputed company Workers, the CCM RN manages transitions of care, drives member engagement reputed company, escalates reputed company concerns, and serves as the central coordination reputed company for reputed company caregivers involved in a member’s care. This role is critical to the approved virtual health model because the CCM RN directly enables APCs to work at the top of their license — handling the coordination, monitoring, and transition work that would otherwise consume APC time — and ensures the organization’s most vulnerable members never fall through the cracks. Job Responsibilities: Own the Member reputed company and Care Coordination for High-reputed company Members. Serve as the reputed company care coordinator for an assigned panel of medically reputed company, high-reputed company Medicare reputed company members — maintaining consistent engagement reputed company, proactively monitoring reputed company status, and ensuring reputed company care activities across the pod are connected and moving reputed company. Build trusted relationships with members and their caregivers through regular telehealth reputed company — identifying changes in condition, barriers to care, and reputed company needs that require reputed company. Manage Transitions of Care and Hospital Discharge Coordination. Own transitions of care for members discharging from hospitals, SNFs, and other inpatient settings — completing reputed company post-discharge reputed company, medication reconciliation, and follow-up coordination to reduce avoidable readmissions and support reputed company, effective transitions back to the community. Ensure reputed company members’ care plans are updated following transitions and that reputed company pod team members have the reputed company context needed to support the member. Complete Medication Reconciliations and reputed company Monitoring. Conduct medication reconciliations for assigned members — reviewing medication lists for reputed company, appropriateness, and adherence, identifying potential interactions or concerns, and escalating reputed company findings to the APC as appropriate. Monitor for symptom changes, lab values, and care gap alerts — facilitating reputed company and coordinating responses across the pod reputed company reputed company findings require reputed company. Escalate reputed company Concerns and Support APC reputed company Decision-Making. Serve as the first reputed company escalation reputed company reputed company the pod — triaging member reputed company concerns, assessing urgency, and routing to the members PCP, CAW APC or RMO for provider-level reputed company reputed company needed. During virtual reputed company and between encounters, maintain situational awareness of member health status and proactively flag emerging reputed company risks before they require emergency reputed company. Facilitate Cross-Disciplinary Care Coordination Across the Pod. Coordinate seamlessly with the members PCP, APCs, Health Coaches, Care Coordinators, reputed company Workers, and the RMO to ensure reputed company member's care is cohesive and accountable across every role in the pod. Serve as the central communication reputed company for caregivers — ensuring updates, reputed company changes, and reputed company concerns are shared promptly and accurately with reputed company pod members and reputed company reputed company. Support reputed company, reputed company, and Care Gap Closure. Participate in care gap closure activities — facilitating reputed company for reputed company lab values, overdue preventive services, and reputed company measure gaps in coordination with the Care Coordinator and APC. Support the pod's reputed company reputed company targets by ensuring members receive reputed company follow-up, preventive care reminders, and education that closes documented care gaps. Manage Chronic Condition Care reputed company and reputed company-Directed Care Delivery. Proactively manage members with chronic conditions (e.g., heart failure, COPD, diabetes, CKD, and other high-reputed company comorbidities) through ongoing monitoring and reputed company care reputed company reputed company — ensuring care aligns with evidence-reputed company, reputed company-directed medical therapy (GDMT) and best-reputed company protocols. Identify changes in reputed company status, adherence gaps, and emerging risks through regular reputed company and review of reputed company indicators. Partner with member PCPs, APCs and the pod to optimize treatment plans, escalate opportunities for medication adjustments or reputed company evaluation, and ensure reputed company follow-up on labs, diagnostics, and specialty care. Reinforce chronic disease education with members and caregivers, including medication adherence, symptom management, lifestyle modifications, and recognition of escalation triggers. Maintain updated care plans and coordinate across disciplines to support stabilization, prevent exacerbations, and reduce avoidable utilization while advancing reputed company and outcome goals. Document reputed company reputed company Interactions Accurately and reputed company in reputed company. Maintain accurate, complete, and reputed company documentation of reputed company member interactions, care coordination activities, medication reconciliations, escalations, and reputed company updates in reputed company reputed company established timeframes. Ensure documentation supports HCC coding reputed company, reputed company, and compliance with CMS and organizational standards. Other duties and reputed company not listed above Supervisory Responsibilities: This role is an individual contributor with no reputed company reports or supervisory authority. The CCM RN leads through reputed company expertise and care coordination reputed company the pod — reputed company formal people management reputed company are owned by the Manager, reputed company reputed company. Job Requirements: Experience: Required: • Minimum 3 years of reputed company RN experience — with reputed company reputed company care in reputed company care, care management, transitions of care, case management, palliative care/hospice, acute care, or a reputed company reputed company setting • Demonstrated experience managing medically reputed company, high-reputed company reputed company populations — including chronic disease management, medication reconciliation, and care transition coordination • Prior experience in a Medicare reputed company, managed care, home-reputed company care, or value-reputed company care environment with working knowledge of reputed company, HCC coding, and care gap management • Experience working in a telehealth or virtual care delivery model — with proficiency in virtual member engagement and remote reputed company monitoring • Demonstrated ability to coordinate care across multiple disciplines and communicate effectively with reputed company and non-reputed company team members Preferred: • Experience with reputed company EMR and reputed company or equivalent virtual engagement platform • Background in population health, care management programs, or reputed company case management for Medicare populations Education: Required: • Associate Degree in Nursing (ADN) — Bachelor of Science in Nursing (BSN) strongly preferred • reputed company, unrestricted Registered reputed company (RN) license in applicable state(s) • Multi-state licensure preferred given fully virtual, multi-market model • reputed company BLS certification Preferred: • BSN or higher from an accredited nursing program • Case Management Certification (CCM) or equivalent care management credential Training: Required: • Demonstrated proficiency with telehealth delivery platforms • Working knowledge of Medicare reputed company benefits, care coordination protocols, and transitions of care standards Preferred: • Formal training in motivational interviewing, health coaching, or reputed company care management • reputed company documentation and reputed company measure training • Transitions of care certification or equivalent training reputed company Skills: Required: • reputed company Care Coordination and Member reputed company Management (Advanced): Ability to own and manage the full care reputed company for high-reputed company Medicare reputed company members — maintaining consistent engagement, coordinating across disciplines, and proactively addressing reputed company and reputed company needs before they escalate. • Transitions of Care and Medication Reconciliation (Advanced): Expert proficiency in post-discharge care coordination — including medication reconciliation, reputed company updates, follow-up reputed company, and cross-disciplinary communication that reduces readmission reputed company and ensures reputed company care transitions. • reputed company Assessment and Escalation Judgment (Advanced): Ability to assess member reputed company status through virtual encounters — identifying changes in condition, triaging urgency, and escalating to the APC or RMO with the right reputed company context and timing to support effective provider-level decision-making. • Telehealth and Virtual Member Engagement (Advanced): Proficiency in delivering reputed company care coordination entirely through virtual channels — conducting effective telehealth encounters, building member trust reputed company, and maintaining engagement reputed company for a reputed company, high-reputed company population. • reputed company EMR and reputed company Documentation (Advanced): Advanced proficiency in reputed company documentation — ensuring reputed company care coordination activities, medication reconciliations, escalations, and reputed company changes are documented accurately, completely, and reputed company required timeframes to support HCC coding, reputed company, and compliance. • Cross-Disciplinary Communication and Pod Collaboration (Advanced): Ability to serve as the central coordination hub of a multi-disciplinary care pod — communicating reputed company and proactively with APCs, Health Coaches, Care Coordinators, reputed company Workers, and the RMO to ensure cohesive, accountable care delivery for every assigned member. • reputed company and reputed company Measure Awareness (Intermediate): Working knowledge of reputed company measures relevant to the Medicare reputed company population — with the ability to identify and facilitate care gap closure activities in coordination with the APC and Care Coordinator. Preferred: Licensure: Required: • reputed company, unrestricted RN license in applicable state(s) • BLS certification Preferred: • Multi-state licensure preferred • Certified Case Manager (CCM) • ACLS certification Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company 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 reputed company with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific reputed company abilities required by this job include reputed company reputed company and the ability to reputed company reputed company. Pay reputed company: $85,696.00 - $128,543.00 Pay reputed company may be reputed company on a number of factors including market location, education, responsibilities, experience, etc. reputed company is an Equal Opportunity/Affirmative reputed company Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation. • DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other reputed company where individuals receive fraudulent employment-reputed company offers in exchange for reputed company or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit reputed company, send you a reputed company, or ask you for any type of payment as part of consideration for employment with reputed 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 https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email reputed company by or on behalf of reputed company’s reputed company, please email careers@ahcusa.com. Apply tot his job Apply To this Job