Description

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

Job Summary

The Health Plan Nurse Coordinator Community Supports - (HPNC CS) is a Registered Nurse who is assigned to the Community Support unit. The HPNC performs utilization management activities, which may include telephonic or onsite clinical reviews, care coordination, or transition of care for support for Members eligible for Community Supports (CS). The HPNC-CS serves as a supportive resource for CS providers regarding authorization processing, CS services, and plan benefits, aiming to support Members in CS. Bilingual in Spanish may be required for positions that primarily interacts 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
• Comply with regulatory standards of governing agency
• Adhere to mandated reporting requirements as per professional licensing requirements
• Function as a collaborative member of Medical Management/Health Services’ multi-disciplinary team
• Attend and actively participate in department meetings
• Collaborate with CS Program Manager to develop audit tools, report templates, or other CS forms/documents as requested.
• Attend CS care coordination meetings, as needed.
• Participate in meetings/committees related to CS
• Identify and report quality of care concerns to management and appropriate departments for follow up
• Perform accurate and timely prospective (pre-service) and retrospective (post-Service) reviews for services requiring prior authorization
• Conduct chart audits to ensure CS providers are providing the core components: outreach initiatives, comprehensive assessments, care plans, interventions, outreach documentation, and obtaining releases of information
• Apply utilization review principles, practices, and guidelines for members in skilled nursing and long-term care facilities
• Perform selective claims review
• 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
• Embrace innovative care strategies that build value-based programs
• Keep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice
• Assist with transitioning members from CS to lower level of care management in collaboration with CS providers
• Apply and interpret established clinical guidelines and/or benefits limitation
• Adhere to regulatory timeline standards for processing, reviewing, and completing reviews
• Act as a mentor to new HPNC’s in Community Supports
• Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

Required:

• Professional demeanor with strong multi-tasking, organizational, and time-management skills
• Able to work effectively individually and collaboratively in a cross-functional team environment
• Utilization of accurate decision-making skills to support the appropriateness and medical necessity of requested services, including the accurate application and citation of sources
• 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
• Positivity, flexibility, and openness toward operational changes
• Ability to compose clear, professional, and grammatically correct correspondence
• Ability to meet timelines and deadlines for daily responsibilities and long-term projects
• Exceptional research, planning, problem-solving, critical thinking, and attention to detail.
• Proficient understanding of Medi-Cal coverage and limitations
• Proficiency in care management activities such as assessment completion, care plan development, monitoring and follow up
• Ability to work directly and collaboratively with CS providers, members and internal CenCal Health departments.

Desired:

• Knowledge of Medi-Cal and/or Medicare health care 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
• Understanding of basic case and disease management concepts, principles and practices
• Understanding of basic quality improvement and population health concepts, principles, and practices

Education and Experience

Required:

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.