A Registed Nurse Care Manager (RNCTM) contributes to AHF by satisfying the AHF Core Measure of being Patient Centered, regulatory & contractual compliance requirements and AHF's North Star mission. The RNCTM position focuses on removing access to care/community resource barriers and improving health outcomes, as well as health equity by ensures timely case processing of grievances, including access to care & quality of care (QOC) cases, QOC Potential Quality Issue (PQI) investigations, and critical incident identification, tracking, ad monitoring. This role will also decrease the Division of Medicine (DOM) prior authorization denial rate, which also removes access to care barriers and improves AHF patient outcomes.
A RNCTM enhances the reputation of AHF by utilizing core principles of Risk Management to cultivate and facilitate essential functions for AHF patients.
You will be a passionate advocate for our top initiatives.
To be successful as a RNCTM it is crucial to ensure that the AHF Core Values and Mission stay top of mind with all that you do. At AHF we are nimble and able to adapt in a dynamic environment to assist in providing the best experience for our clients and workplace for our employees.
AHF has a collaborative organizational structure where staff are accountable to multiple leaders.
The RNCTM will work as a part of a close-knit team to ensure that day-to-day RM activities are executed in accordance with AHF policies and procedures that adhere to regulatory, contractual and accreditation requirements. This role works collaboratively with all AHF staff and ensures timely triaging and processing of grievances, PQIs, & related investigations. The RNCTM also mitigates prior authorization denials & appeals submitted by the AHF Healthcare Centers by trending common denial reasons, educating providers on documentation best practices, and promoting awareness of payer-specific requirements and updates to nursing/referral teams.
Licenses and Certifications:
CA Registered Nurse (RN) License required.
Multistate RN License within 6 months of hire required.
Managed Care experience preferred.
Grievance/Appeals/Quality Improvement experience preferred.
Bilingual Spanish preferred.
