RN Case Manager – Transition of Care (Outpatient, Bilingual Spanish or Vietnamese) – Remote

Alignment Health 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 built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Alignment Health is seeking a remote, bilingual Spanish or Vietnamese, RN Case Manager, TOC (Transition of Care) to join the case management team (Must have California RN License). The Case Manager – Transitions of Care (Outpatient) ensures a smooth transition for members after a hospital or Skilled nursing facility discharge by coordinating care, providing resources, and educating members/families about the post discharge care plan to support optimal health outcomes. Responsibilities include all aspects and activities responsible for monitoring the delivery of care to Alignment Healthcare members. Performs duties mostly telephonically. Schedule: Must be willing to work Mon - Fri, 8am - 5pm Pacific Time

Develop and implement individualized discharge plans in collaboration with the interdisciplinary team, patients, and families. Coordinate with healthcare providers, home health agencies, rehabilitation facilities, and community resources to ensure continuity of care. Facilitate timely referrals to necessary services, including home health, physical therapy, occupational therapy, and social support. Monitor patient progress and adjust discharge plans as needed. Provide comprehensive education to patients and families regarding their medical condition, treatment plan, medications, and post-discharge care instructions. Answer questions and address concerns related to discharge planning and post-discharge care. Empower patients and families to actively participate in their care and self-management. Identify and access appropriate resources and services for patients and families, including financial assistance, transportation, and community support programs. Advocate for patients' needs and ensure access to necessary resources. Maintain accurate and up-to-date patient records and documentation related to discharge planning and post-discharge care. Communicate effectively with all members of the interdisciplinary team, patients, and families. Participate in care conferences and team meetings to ensure effective communication and coordination of care. Participate in quality improvement activities to identify areas for improvement in discharge planning and post-discharge care. Stay current with best practices and trends in care management and discharge planning.