Health Plan Nurse Coordinator

1 week ago

Santa Barbara, California, United States CenCal Health Full time
Job Summary

The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse who is assigned the Utilization Management role at CenCal Health. This position reports to the Program's Manager or their designee of the assigned unit.

The HPNC will perform utilization management activities, which may include telephonic or onsite clinical review; care coordination or transition; or a combination of all.

Bilingual in Spanish may be required for positions that primarily require interaction with members.

Duties and Responsibilities
  • Comply with HIPAA, Privacy, and Confidentiality laws and regulations.
  • Adhere to Health Plan, Medical Management and Health Services policies and procedures.
  • Be abreast on clinical knowledge related to disease processes.
  • Effectively communicate, verbally and in writing, with providers, members, vendors, and other healthcare providers and in a timely, respectful and professional manner.
  • Function as a collaborative member of Medical Management/Health Services' multi-disciplinary medical management team.
  • Identify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow up.
  • Support and collaborate with the management, medical management and health services team members in the implementation and management of Utilization Management, Care Coordination, and Care Transition activities.
  • As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job duties.
  • Adhere to mandated reporting requirements appropriate to professional licensing requirements.
  • Comply with regulatory standards of governing agency.
  • Be positive, flexible, and open toward operational changes.
  • Attend and actively participate in department meetings.
  • Support and work collaboratively with the Medical Management and Health Services management team in the implementation and management of UM/ activities.
  • Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member's quality of care.
  • Keep abreast of healthcare benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice.
  • Embrace innovative care strategies that are build value-based programs.
  • Act as a liaison primarily to providers and CenCal Health employees regarding UM processes and its operational standards.
  • Timely review of request for referrals and services.
  • Application and interpretation of established clinical guidelines and/or benefits limitations.
  • Accurate decision-making skills to support the appropriateness and medical necessity of requested services.
  • Perform accurate and timely prospective (pre-service) review for services requiring prior authorization.
  • Perform accurate and timely concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings.
  • Perform accurate and timely retrospective (post-service) review for services that required prior authorization but was not obtained by the provider before rendering services.
  • Document clear and concise case review summaries.
  • Compose appropriate and accurate draft notice of action, non-coverage, or other regulatory required notices to members and providers regarding UM decisions.
  • Accurate application and citation of sources used in decision-making.
  • Adhere to regulatory timeline standards for processing, reviewing, and completing reviews.
  • Apply utilization review principles, practices, and guidelines as appropriate to members in skilled nursing and long-term care facilities.
  • Perform selective claims review.
  • As assigned, perform onsite review of members in the acute hospital, skilled nursing facility, and other inpatient setting.
  • As assigned, conduct face-to-face assessment of the member and/or with their authorized representative, family, caregiver, etc. to complete necessary assessments, such as the Community-Based Adult Services (CBAS) assessment tool.
  • Other duties as assigned.
QualificationsKnowledge/Skills/Abilities
  • Professional demeanor.
  • Demonstrate strong multi-tasking, organizational, and time-management skills.
  • Demonstrate clinical knowledge of adult or health conditions and disease processes.
  • Able to work effectively individually and collaboratively in a cross-functional team environment.
  • Able to communicate professionally by phone, with members and their families, physicians, providers, and other healthcare providers; in writing, and in-person (in a one-to-one or group setting) and to demonstrate excellent interpersonal communication skills.
  • Able to compose clear, professional, and grammatically correct correspondence to members and providers.
  • Able to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projects.
  • Demonstrate ability to accurately apply and interpret clinical guidelines.
  • Demonstrate proficiency in organizing and managing work assignment.
  • Demonstrate proficiency in utilizing IT UM database and electronic clinical guidelines.
  • Able to compose grammatically correct Notice of Actions or other denial notices using the correct notice type and template with accurate source citation and limited errors.
  • Proficient understanding of Medi-Cal coverage and limitations.
  • For HPNC assigned to Pediatric Department, demonstrate proficiency in CCS eligibility and clinical guidelines.
  • Act as a mentor to new HPNC in Utilization Management.
Desired Overall
  • Knowledge of Medi-Cal and/or Medicare healthcare benefits, managed care regulations, including benefits and contract limitations, delivery and reimbursement systems, and role of medical management activities.
  • Understand basic utilization review principles and practices.
  • Understand basic case and disease management concepts, principles, and practices described in the Case Management Society of America.
  • Understand basic quality improvement and population health concepts, principles, and practices.
Education and ExperienceRequired
  • Current active, unrestricted, California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years' experience in this nursing role.
Desired
  • Certification in case management, utilization, quality, or healthcare management, such as CCM, CMCN, CPHQ, HCQM, CPUM, CPUR or board certification in area of specialty.
  • Prior UM, experience in a managed care setting.

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