Transition of Care Nurse

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.

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. Supports Transitions of Care (TOC) to ensure timely access and coordination of follow up care, adherence to discharge plans and member education to support improved health outcomes. Coordinates and monitors Alignment Health 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

Supports inpatient program engagement for Alignment members currently inpatient in an acute or skilled nursing facility setting. Manages Transitions of Care (TOC) for members moving from inpatient, SNF, and emergency services to lower level of care facilities or home, in accordance with established workflows. Manages TOC activities including post-discharge follow up appointment scheduling and monitoring for kept appointments Ensures member access to services appropriate to their health needs. Identifies, assesses, and manages high risk/complex members per established criteria and health risk status. Develops, monitors, and evaluates the effectiveness of the care management plans and modifies, as necessary to support improved health outcomes. Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners, and specialists on the development of care management treatment plans. Assists in problem solving with providers, claims or service issues. Measures the effectiveness of interventions to determine case management outcomes. 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.