Complex Care Registered Nurse

Alignment Healthcare•Modesto, CA

2d•Remote

About The Position

Alignment Health is dedicated to serving seniors and the chronically ill by transforming healthcare. As a Complex Care RN (CCM RN), you will be the clinical core of the Care Anywhere pod, managing the member journey, coordinating care across various disciplines, and ensuring high-acuity Medicare Advantage members receive proactive, coordinated care in a virtual setting. You will work within a team-based pod, including APCs, Health Coaches, Care Coordinators, Medical Assistants, and Social Workers. Your role is crucial for enabling APCs to work at their full potential by handling coordination, monitoring, and transition work, ensuring the most vulnerable members receive continuous care.

Requirements

Minimum 3 years of clinical RN experience — with 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
Prior experience in a Medicare Advantage, managed care, home-based care, or value-based care environment with working knowledge of HEDIS, HCC coding, and care gap management
Experience working in a telehealth or virtual care delivery model — with proficiency in virtual member engagement and remote clinical monitoring
Demonstrated ability to coordinate care across multiple disciplines and communicate effectively with clinical and non-clinical team members
Associate Degree in Nursing (ADN) — Bachelor of Science in Nursing (BSN) strongly preferred
Active, unrestricted Registered Nurse (RN) license in applicable state(s)
Multi-state licensure preferred given fully virtual, multi-market model
Current BLS certification
Demonstrated proficiency with telehealth delivery platforms
Working knowledge of Medicare Advantage benefits, care coordination protocols, and transitions of care standards
Complex Care Coordination and Member Journey Management (Advanced): Ability to own and manage the full care journey for high-acuity Medicare Advantage members — maintaining consistent engagement, coordinating across disciplines, and proactively addressing clinical and social needs before they escalate.
Transitions of Care and Medication Reconciliation (Advanced): Expert proficiency in post-discharge care coordination — including medication reconciliation, care plan updates, follow-up outreach, and cross-disciplinary communication that reduces readmission risk and ensures safe care transitions.
Clinical Assessment and Escalation Judgment (Advanced): Ability to assess member clinical status through virtual encounters — identifying changes in condition, triaging urgency, and escalating to the APC or RMO with the right clinical context and timing to support effective provider-level decision-making.
Telehealth and Virtual Member Engagement (Advanced): Proficiency in delivering clinical care coordination entirely through virtual channels — conducting effective telehealth encounters, building member trust remotely, and maintaining engagement cadence for a complex, high-risk population.
Athena EMR and Clinical Documentation (Advanced): Advanced proficiency in Athena documentation — ensuring all care coordination activities, medication reconciliations, escalations, and care plan changes are documented accurately, completely, and within required timeframes to support HCC coding, care continuity, and compliance.
Cross-Disciplinary Communication and Pod Collaboration (Advanced): Ability to serve as the central coordination hub of a multi-disciplinary care pod — communicating clearly and proactively with APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure cohesive, accountable care delivery for every assigned member.
HEDIS and Quality Measure Awareness (Intermediate): Working knowledge of HEDIS measures relevant to the Medicare Advantage population — with the ability to identify and facilitate care gap closure activities in coordination with the APC and Care Coordinator.
Active, unrestricted RN license in applicable state(s)
BLS certification

Nice To Haves

BSN or higher from an accredited nursing program
Case Management Certification (CCM) or 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
Experience with Athena EMR and TalkDesk or equivalent virtual engagement platform
Background in population health, care management programs, or complex case management for Medicare populations
Multi-state licensure preferred
Certified Case Manager (CCM)
ACLS certification

Responsibilities

Own the Member Journey and Care Coordination for High-Acuity Members: Serve as the primary care coordinator for an assigned panel of medically complex, high-risk Medicare Advantage members, maintaining consistent engagement, proactively monitoring clinical status, and ensuring all care activities across the pod are connected and moving forward.
Build trusted relationships with members and their caregivers through regular telehealth outreach, identifying changes in condition, barriers to care, and social needs that require intervention.
Manage Transitions of Care and Hospital Discharge Coordination: Own transitions of care for members discharging from hospitals, SNFs, and other inpatient settings, completing timely post-discharge outreach, medication reconciliation, and follow-up coordination to reduce avoidable readmissions and support safe transitions back to the community.
Ensure all members’ care plans are updated following transitions and that all pod team members have the clinical context needed to support the member.
Complete Medication Reconciliations and Clinical Monitoring: Conduct medication reconciliations for assigned members, reviewing medication lists for accuracy, appropriateness, and adherence, identifying potential interactions or concerns, and escalating clinical findings to the APC as appropriate.
Monitor for symptom changes, lab values, and care gap alerts, facilitating outreach and coordinating responses across the pod when abnormal findings require action.
Escalate Clinical Concerns and Support APC Clinical Decision-Making: Serve as the first clinical escalation point within the pod, triaging member clinical concerns, assessing urgency, and routing to the members PCP, CAW APC or RMO for provider-level intervention when needed.
During virtual visits and between encounters, maintain situational awareness of member health status and proactively flag emerging clinical risks before they require emergency intervention.
Facilitate Cross-Disciplinary Care Coordination Across the Pod: Coordinate seamlessly with the members PCP, APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure each member's care is cohesive and accountable across every role in the pod.
Serve as the central communication point for caregivers, ensuring updates, care plan changes, and clinical concerns are shared promptly and accurately with all pod members and external care partners.
Support HEDIS, Quality, and Care Gap Closure: Participate in care gap closure activities, facilitating 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.
Manage Chronic Condition Care Pathways and Guideline-Directed Care Delivery: 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, ensuring 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, escalate opportunities for medication adjustments or further evaluation, and ensure timely 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 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 in Athena within established timeframes.
Ensure documentation supports HCC coding accuracy, care continuity, and compliance with CMS and organizational standards.
Other duties and projects not listed above.