RN Care Team Manager
About the role
The Registered Nurse Care Manager (RNCTM) contributes to AHF by satisfying the AHF Core Measure of being Patient Centered, meeting regulatory and contractual compliance requirements, and advancing AHF’s North Star mission. This role focuses on removing barriers to care and community resources, improving health outcomes, and promoting health equity by ensuring timely case processing of grievances, including access-to-care and quality-of-care (QOC) cases, QOC Potential Quality Issue (PQI) investigations, and critical incident identification, tracking, and monitoring.
The RNCTM also works to decrease the Division of Medicine (DOM) prior authorization denial rate, further removing access-to-care barriers and improving patient outcomes. By utilizing core principles of Risk Management, the RNCTM enhances AHF’s reputation and facilitates essential functions for patients. As a passionate advocate for AHF’s top initiatives, the RNCTM ensures that AHF’s Core Values and Mission remain central to all activities.
AHF operates in a dynamic environment, requiring adaptability to provide the best experience for clients and a collaborative workplace for employees. The RNCTM will work as part of a close-knit team to execute day-to-day Risk Management activities in accordance with AHF policies and procedures, adhering to regulatory, contractual, and accreditation requirements. This role involves collaborating with all AHF staff to ensure timely triaging and processing of grievances, PQIs, and related investigations. Additionally, the RNCTM mitigates prior authorization denials and appeals by trending common denial reasons, educating providers on documentation best practices, and promoting awareness of payer-specific requirements among nursing and referral teams.
Requirements
- Active California Registered Nurse (RN) License required.
- Multistate RN License required within 6 months of hire.
- Managed Care experience preferred.
- Experience with grievances, appeals, or quality improvement preferred.
- Bilingual (Spanish) preferred.