Health Plan Nurse Coordinator Iii

4 weeks ago

Santa Barbara, United States CenCal Health Full time

**Salary Range**: $101,007 - $151,510

**Job Summary**

The Health Plan Nurse Coordinator III Lead (HPNC III Lead) is a Registered Nurse assigned to the Enhanced Care Management (ECM) operational unit. The HPNC III Lead performs utilization management activities, telephonic or onsite clinical reviews, care coordination, and transitional care services. This role supports the efficiency and cohesion of the ECM Team by leading team huddles to facilitate effective communication and address immediate concerns. The HPNC III Lead, also serves as an exemplary employee, modeling core competencies and inspiring team members. Bilingual in Spanish may be required for positions that primarily interacts with members.

**Duties & Responsibilities**
- Create, orient, and train new HPNCs in duties and responsibilities, operational processes and general CenCal operations
- Provide honest and timely feedback to management on new employee performance
- Monitor unit responsibilities and provide timely feedback to management
- Support and collaborate with management and health services team members in the assessment, implementation and management of Utilization Management, Case Management, Enhanced Care Management, Disease Management, Quality Improvement, Care Coordination, and Care Transition activities
- Conduct ECM Utilization Management and Member Coordination activities
- Assist with complex Utilization Management and Member Care Coordination requests
- Identify and report quality of care concerns to management and appropriate departments for follow up
- Adhere to mandated reporting requirements and comply with regulatory standards
- Perform accurate and timely prospective (pre-service) and retrospective (post-service) review for services requiring prior authorization
- Document clear and concise case review summaries and compose appropriate regulatory notices to members and providers regarding UM decisions
- Conduct chart audits and face-to-face assessments as needed
- Lead team huddles to facilitate effective communication and address immediate concerns
- Act as a liaison to providers and CenCal employees regarding UM processes and standards
- Collaborate with Provider Relations to train ECM providers for successful service delivery
- Support and work collaboratively with the Health Services management team in UM/CM/ECM/DM/QI activities
- Keep abreast of health care benefits, regulatory requirements, disease processes, treatment modalities, and professional nursing standards
- Embrace innovative care strategies that are build value based programs
- Attend and actively participate in department meetings
- Perform selective claims and appeals reviews
- Provide final review of Notice of Actions or other determination notices for content and citation accuracy
- Perform onsite reviews and face-to-face assessments as assigned for members in the acute hospital, skilled nursing facility, and other inpatient setting
- Meet timelines and deadlines for daily work responsibilities and long term projects
- Adhere to regulatory timeline standards for processing, reviewing, and completing reviews
- Other duties as assigned

**Knowledge/Skills/Abilities**

**Required**:

- Comply with HIPAA, Privacy, and Confidentiality laws and regulations
- Ability to perform the basic duties of another non-core Health Services unit
- Basic clinical knowledge of either adult or pediatric health conditions and disease processes
- Professional demeanor, positivity, flexibility, and openness to operational changes
- Ability to understand and address deficiencies in operational reports
- Strong multi-tasking, organizational, and time-management skills
- Proficiency in Microsoft Office and required electronic databases
- Ability to work effectively individually and collaboratively in a cross-functional team environment
- Excellent interpersonal communications skills, able to communicate professionally by phone, in writing, and in-person with members, their families, physicians, providers, and other healthcare providers
- Ability to compose clear, professional, and grammatically correct correspondence
- Proficiency with required electronic databases for documenting and summarizing findings

**Desired**:

- Knowledge of Medi-Cal and/or Medicare health care benefits, managed care regulations, and medical management activities
- Understanding of basic utilization review principles and practices
- Understanding of basic case and disease management concepts and practices
- Understanding of basic quality improvement and population health concepts and practices

**Education & Experience**
- Current active, unrestricted, California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years’ experience in a nursing role.
- A minimum of one (1) year of experience in a Lead, Supervisory or other management role
- A minimum of three (3) years’ experience in UM, ECM, CM, DM or QI in a MCO, HMO, PPO, hospital, clinic, or outpatient se

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