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Registered Nurse

2 months ago

Santa Barbara, California, United States Cencal Health Full time
Job Overview

Position Type: Full Time

Salary Range: Undisclosed

Job Category: Medical Management

Salary Range: $82,165 - $119,140

Position Summary

The Health Plan Nurse Coordinator for Enhanced Care Management (HPNC ECM) is a dedicated Registered Nurse responsible for overseeing the Enhanced Care Management unit. This role involves conducting utilization management activities, which may include telephonic or onsite clinical assessments, care coordination, and facilitating transitions of care for members eligible for Enhanced Care Management.

The HPNC ECM acts as a vital resource for ECM providers, assisting with authorization processes, core ECM services, and understanding plan benefits, all aimed at supporting members in their care journey. Bilingual proficiency in Spanish may be necessary for roles requiring significant member interaction.

Key Responsibilities

  • Ensure compliance with HIPAA, Privacy, and Confidentiality regulations.
  • Follow Health Plan, Medical Management, and Health Services policies and procedures.
  • Communicate effectively, both verbally and in writing, with providers, members, and other healthcare professionals in a respectful and timely manner.
  • Collaborate as part of a multi-disciplinary medical management team.
  • Identify and report quality of care issues to management and relevant departments.
  • Adhere to mandated reporting requirements as per professional licensing standards.
  • Stay informed about healthcare benefits, regulatory requirements, and best practices in patient care.
  • Implement innovative care strategies that enhance value-based programs.
  • Conduct utilization management duties, including pre-service and post-service reviews.
  • Document case reviews and compose necessary notices regarding utilization management decisions.
  • Participate in ECM care coordination meetings and assist in transitioning members to lower levels of care.
  • Engage in meetings and committees related to Enhanced Care Management.
  • Perform additional duties as assigned.

Qualifications

Required:
  • Current, unrestricted California Registered Nurse (RN) or Nurse Practitioner (NP) License with a minimum of two years of relevant experience.
  • Professional demeanor with strong organizational and time-management skills.
  • Able to work effectively both independently and within a team environment.
  • Excellent communication skills, both written and verbal.
  • Proficient in care management activities including assessments and care plan development.
  • Ability to mentor new staff within the Enhanced Care Management team.

Desired:
  • Certification in case management or related fields.
  • Knowledge of Medi-Cal and Medicare regulations.
  • Understanding of utilization review principles and quality improvement concepts.