Hybrid RN Case Manager

AHI agilon health, inc. is seeking a Hybrid RN Case Manager based in the Dayton, Ohio area. This role splits time between the Dayton office and remote work from home.

About the Role

Manages targeted patient populations to achieve efficient and effective care delivery. Coordinates, facilitates, monitors, and evaluates interventions to achieve desired outcomes. Works as part of an interdisciplinary team to guide high-risk patients across care delivery sites, including inpatient, ambulatory, and post-acute care settings. Ensures continuity of care through evidence-based methods such as medication reconciliation, self-management plans, health education, and referrals.

Responsibilities

• Identifies, evaluates, engages, and enrolls high-risk patients of specified populations.
• Performs complete assessments of patient’s current health status, including barriers to optimal health and available resources.
• Develops an initial Plan of Care and Self-Management Plan in collaboration with the patient, family, caregivers, providers, and healthcare team members.
• Facilitates and monitors the implementation of the Plan of Care, coordinating patient and family participation.
• Uses knowledge of community resources to facilitate achievement of goals and coordinates patient education using evidence-based methods such as teach-back.
• Performs home visits as necessary to evaluate barriers to self-management goals and develops strategies to overcome them.
• Participates in the development and execution of the Plan of Care across acute, post-acute, and home settings.
• Demonstrates expertise in case management and serves as a resource to the interdisciplinary healthcare team.
• Integrates knowledge of external and internal regulatory requirements into case management.
• Collaborates with inpatient, ambulatory, and community resources to facilitate continuity of care.
• Serves as a consistent point of contact for patients across clinical settings and facilitates referrals to other disciplines and programs.
• Utilizes efficiency and effectiveness indicators (e.g., Process Metrics, NCQA, URAC, HEDIS) in care coordination.
• Documents care planning, interventions, and evaluations in medical records and designated case management tools.
• Complies with OSHA and HIPAA regulations and adheres to company policies and procedures.
• Provides excellent customer service, demonstrating awareness and sensitivity to client needs.
• Engages in professional growth, including acquiring new skills and knowledge.
• Participates in projects and other duties as assigned by market leadership.

Requirements

• Bachelor’s Degree or professional certification/license with 2-4 years of experience; 2 years of case management preferred.
• Registered Nurse (RN) with an active license in the state of Ohio; BSN preferred.
• Strong verbal and communication skills, with the ability to handle stressful situations appropriately.
• Ability to work flexible hours as needed.
• Must be based in the Dayton, Ohio area.