Remote Complex Care Registered Nurse - California Residents Only (Active California RN License Required | Bilingual English/Spanish Preferred)

Alignment Health•Fresno, CA

2d•$85,696 - $128,543•Remote

About The Position

The Complex Care RN (CCM RN) serves as the clinical center of the Care Anywhere pod, owning the member journey and coordinating care across disciplines for high-acuity Medicare Advantage members in a fully virtual delivery model. Working alongside APCs, Health Coaches, Care Coordinators, Medical Assistants, and Social Workers, the RN manages transitions of care, maintains member engagement, escalates clinical concerns, and coordinates communication among caregivers. The role enables APCs to work at the top of their license and helps ensure vulnerable members receive timely, proactive, coordinated care. The RN manages an assigned panel of medically complex, high-risk members; builds relationships with members and caregivers through telehealth outreach; monitors clinical status; coordinates hospital and facility discharges; completes medication reconciliations; and supports chronic condition care pathways. The RN triages and escalates concerns to providers, coordinates across the care pod and external partners, supports HEDIS and care-gap closure activities, and documents interactions and care plan updates in Athena. This is an individual contributor role with no direct reports or supervisory authority.

Requirements

At least 3 years of clinical RN experience, including 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.
Experience in Medicare Advantage, managed care, home-based care, or value-based care, with working knowledge of HEDIS, HCC coding, and care-gap management.
Experience working in a telehealth or virtual care delivery model, including proficiency in virtual member engagement and remote clinical monitoring.
Ability to coordinate care across multiple disciplines and communicate effectively with clinical and non-clinical team members.
Associate Degree in Nursing (ADN).
Active, unrestricted Registered Nurse (RN) license in applicable state(s).
Current BLS certification.
Demonstrated proficiency with telehealth delivery platforms.
Working knowledge of Medicare Advantage benefits, care coordination protocols, and transitions of care standards.
Advanced ability to coordinate complex care and manage the member journey for high-acuity Medicare Advantage members.
Advanced proficiency in transitions of care and medication reconciliation, including post-discharge coordination and follow-up.
Advanced clinical assessment and escalation judgment in virtual encounters.
Advanced telehealth and virtual member engagement proficiency.
Advanced Athena EMR documentation proficiency.
Advanced cross-disciplinary communication and collaboration in a care pod.
Intermediate working knowledge of HEDIS measures relevant to Medicare Advantage and care-gap closure.

Nice To Haves

Bachelor of Science in Nursing (BSN) or higher from an accredited nursing program.
Experience with Athena EMR and TalkDesk or an equivalent virtual engagement platform.
Background in population health, care management programs, or complex case management for Medicare populations.
Multi-state licensure.
Case Management Certification (CCM) or an equivalent care management credential.
Formal training in motivational interviewing, health coaching, or complex care management.
HEDIS documentation and quality measure training.
Transitions of care certification or equivalent training.
ACLS certification.

Responsibilities

Own care coordination and the member journey for an assigned panel of high-acuity Medicare Advantage members, including maintaining engagement cadence and monitoring clinical status.
Build trusted relationships with members and caregivers through telehealth outreach; identify changes in condition, barriers to care, and social needs requiring intervention.
Coordinate transitions of care for members discharged from hospitals, skilled nursing facilities, and other inpatient settings, including timely outreach, medication reconciliation, follow-up, and care plan updates.
Review medication lists for accuracy, appropriateness, adherence, and potential interactions; escalate clinical findings to the APC as appropriate.
Monitor symptoms, lab values, and care-gap alerts; coordinate responses across the care pod when findings require action.
Triage member clinical concerns, assess urgency, and route concerns to the member’s PCP, CAW APC, or RMO for provider-level intervention when needed.
Maintain awareness of member health status during and between virtual visits and proactively flag emerging clinical risks.
Coordinate care with PCPs, APCs, Health Coaches, Care Coordinators, Social Workers, the RMO, caregivers, and external care partners; share updates and clinical concerns promptly and accurately.
Support HEDIS, quality, and care-gap closure activities, including outreach for abnormal lab values, overdue preventive services, and measure gaps.
Manage chronic condition care pathways through ongoing monitoring, structured oversight, education, care-plan maintenance, and coordination of labs, diagnostics, specialty care, and follow-up.
Ensure chronic condition care aligns with evidence-based, guideline-directed medical therapy and best-practice protocols; identify adherence gaps and opportunities for treatment adjustment or further evaluation.
Document member interactions, coordination activities, medication reconciliations, escalations, and care plan updates accurately and timely in Athena to support HCC coding, continuity, and compliance.
Perform other duties and projects not listed above.