Health Plan Nurse Coor. UM Adult
2 weeks ago
While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.
Job Summary
The Health Plan Nurse Coordinator - Adult Utilization Management (HPNC - Adult UM) is a Registered Nurse assigned to the Utilization Management unit. This position reports to the Utilization Management Supervisor or their designee for the assigned unit. The HPNC - Adult UM will be responsible for performing utilization management activities, which may include telephonic or onsite clinical reviews, care coordination, transitions of care, or a combination of these tasks. Bilingual proficiency in Spanish may be required for positions involving frequent interaction with members.
About This Opportunity:
CenCal Health is continuously seeking top talent for Health Plan Nurse Coordinators. While this is not an immediate opening, we actively review applications for future hiring needs. If you are interested in being considered for upcoming opportunities, we encourage you to apply
Why Join Our Talent Pipeline?
- Be among the first to be considered when new positions become available.
- Stay connected with our Talent Acquisition team for future opportunities.
- Explore potential career paths with CenCal Health.
We welcome applications from RN's with Health Plan and healthcare experience, specifically in Utilization Management. If a position matching your background and interest opens, our team will reach out to discuss the next steps.
Next Steps:
By applying to this posting, your resume will be added to our talent pipeline. Our recruiters will contact you if your qualifications align with an available role. Please continue to check our Careers page for active job postings at https://www.cencalhealth.org/explore-cencal-health/careers/.
Duties and Responsibilities
- Comply with HIPAA, Privacy, and Confidentiality laws and regulations.
- Adhere to Health Plan, Medical Management, and Health Services policies and procedures.
- Stay current with clinical knowledge related to disease processes.
- Communicate effectively, both verbally and in writing, with providers, members, vendors, and other healthcare professionals in a timely, respectful, and professional manner.
- Function as an active member of the Medical Management/Health Services multi-disciplinary team.
- Identify and report quality of care concerns to management and, as directed, to the appropriate CenCal Health department for follow-up.
- Collaborate with management, medical management, and health services teams in the implementation and management of Utilization Management, Care Coordination, and Care Transition activities.
- Participate as required in the implementation, assessment, and evaluation of quality improvement activities related to job duties.
- Adhere to mandated reporting requirements according to professional licensing standards.
- Comply with regulatory standards of governing agencies.
- Remain positive, flexible, and open to operational changes.
- Attend and actively participate in department meetings.
- Support and collaborate with the Medical Management and Health Services management teams in implementing and managing UM activities.
- Actively engage in the development, implementation, and evaluation of department initiatives to assess measurable improvements in member quality of care.
- Stay informed about healthcare benefits, limitations, regulatory requirements, disease processes, treatment modalities, community care standards, and professional nursing practices.
- Embrace innovative care strategies that support value-based programs.
- Serve as a liaison to providers and CenCal employees regarding UM processes and operational standards.
- Review requests for referrals and services in a timely manner.
- Apply and interpret established clinical guidelines and benefits limitations.
- Use accurate decision-making skills to support the appropriateness and medical necessity of requested services.
- Conduct accurate and timely prospective (pre-service) reviews for services requiring prior authorization.
- Perform timely concurrent reviews for inpatient care in acute care, subacute, skilled nursing, and long-term care settings.
- Carry out accurate and timely retrospective (post-service) reviews for services requiring prior authorization but not obtained by the provider before service delivery.
- Document clear and concise case review summaries.
- Compose accurate draft notices of action, non-coverage, or other regulatory-required notices to members and providers regarding UM decisions.
- Apply and cite sources accurately in decision-making processes.
- Adhere to regulatory timelines for processing, reviewing, and completing reviews.
- Apply utilization review principles, practices, and guidelines as appropriate for members in skilled nursing and long-term care facilities.
- Conduct selective claims reviews.
- As assigned, perform onsite reviews of members in acute hospitals, skilled nursing facilities, and other inpatient settings.
- As assigned, conduct face-to-face assessments of members and/or their authorized representatives, family, caregivers, etc., to complete necessary assessments (e.g., Community-Based Adult Services (CBAS) assessment tool).
- Perform other duties as assigned.
Required:
- Professional demeanor.
- Strong multi-tasking, organizational, and time-management skills.
- Clinical knowledge of adult or pediatric health conditions and disease processes.
- Ability to work effectively both individually and collaboratively in a cross-functional team environment.
- Excellent communication skills, both verbal and written, with members, their families, physicians, providers, and other healthcare professionals in a professional manner (via phone, in writing, and in-person).
- Ability to compose clear, professional, and grammatically correct correspondence to members and providers.
- Ability to meet deadlines and manage daily work responsibilities, as well as long-term projects.
- Skill in accurately applying and interpreting clinical guidelines.
- Proficiency in organizing and managing work assignments.
- Proficiency in utilizing IT UM databases and electronic clinical guidelines.
- Ability to compose grammatically correct Notices of Action or other denial notices using the correct templates, with accurate source citations and minimal errors.
- Strong understanding of Medi-Cal coverage and limitations.
- For HPNC assigned to Pediatric Department: proficiency in CCS eligibility and clinical guidelines.
- Ability to mentor new HPNCs in Utilization Management.
- Knowledge of Medi-Cal and/or Medicare healthcare benefits, managed care regulations, including benefits and contract limitations, delivery and reimbursement systems, and the role of medical management activities.
- Understanding of basic utilization review principles and practices.
Required:
- Current, active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years of experience in this nursing role.
- Certification in case management, utilization, quality, or healthcare management, such as CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, or board certification in an area of specialty.
- Prior experience in Utilization Management (UM) within a managed care setting.
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