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Health Plan Nurse Coordinator
2 months ago
We are seeking a highly skilled and experienced Health Plan Nurse Coordinator to join our team at Impresiv Health. As a key member of our Utilization Management department, you will play a critical role in ensuring the delivery of high-quality, cost-effective healthcare services to our members.
Key Responsibilities- Utilization Management: Conduct thorough reviews of medical records to determine the medical necessity of requested services, ensuring compliance with regulatory requirements and company policies.
- Clinical Decision-Making: Apply clinical knowledge and expertise to make informed decisions regarding the appropriateness of requested services, taking into account the member's medical history, current condition, and treatment options.
- Communication and Collaboration: Effectively communicate with healthcare providers, members, and other stakeholders to ensure seamless coordination of care and timely resolution of issues.
- Quality Improvement: Identify opportunities for process improvement and contribute to the development and implementation of initiatives to enhance the quality of care and services provided.
- Regulatory Compliance: Ensure adherence to relevant laws, regulations, and company policies, including HIPAA, Medicare, and Medicaid requirements.
- Education and Experience: Current active, unrestricted, California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years' experience in a similar nursing role.
- Knowledge and Skills: In-depth knowledge of Medi-Cal and Medicare health benefits, managed care regulations, benefits, contract limitations, delivery and reimbursement systems, and medical management activities.
- Certifications and Training: Certifications in case management, utilization, quality preferred (CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, etc.).
- Language Skills: Bilingual in Spanish preferred.
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
