Description

California Annual Salary Range: $101,007 - $151,510

The Health Plan Nurse Coordinator III Lead (HPNC III Lead) is at the minimum, a Registered Nurse who is assigned to a Care Management (CM) operational unit. The HPNC III Lead performs comprehensive assessments, care plans, and care coordination for CM members. The HPNC III Lead also serves as the subject matter expert, providing clinical support, training, and mentoring to CM staff.

• Act as the subject matter expert (SME) for the core (assigned) unit’s operational processes
• Adhere to Health Plan and Health Services policies and procedures
• Able to execute approved operational changes
• Effectively communicate, verbally and in writing, with providers, members, vendors, CenCal Health Staff, and other healthcare providers in a timely, clearly, respectful, and professional manner Function as a collaborative member of Health Services’ multi-disciplinary medical management team
• Orient and train/mentor new HPNC to duties and responsibilities, operational processes within the assigned unit, and general CenCal operations
• Provide honest and timely feedback to staff and management on new employee and current staff performance
• As directed, create basic written operational processes and educate the team
• Identify and report quality of care concerns to management and as directed, to the appropriate CenCal Health department for follow-up
• Able to identify and explain program deficiencies and recommend operational improvement opportunities to management
• Be able to monitor unit responsibilities and provide timely feedback to management
• Be able to understand basic operational reports, and as directed, address deficiencies and educate the team
• Support and work collaboratively with the management and health services team members in the implementation and management of Case Management, Disease Management, Care Coordination, and Care Transition activities
• As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as they relate 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 to operational changes
• Attend and actively participate in department meetings
• Actively participate in the development, implementation, and evaluation of department initiatives with the intent to assess any measurable improvements to member’s quality of care
• 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
• Embrace innovative care strategies that build value-based programs
• Coordinate quality and cost-effective medically necessary, health care services for members receiving CM services
• Effectively and efficiently, implement and complete the case management process. This process involves health screening, assessment, planning, facilitating, coordinating, monitoring, and measuring the member’s care, progress, and compliance
• Collaborate with members, their authorized representative, family or caretaker, primary care provider, and other health care providers
• Work collaboratively with multidisciplinary teams to assess, coordinate, and facilitate the needs of members
• Develop, update, and monitor member-centered, individualized care plans that were developed with the member’s input and facilitate necessary services, and establish timelines for case management services, as well as meet regulatory requirements
• Conduct timely telephonic assessments, surveys, and questionnaires that meet policies and regulatory standards
• Accurate and timely determination of member risk levels based on assessment, survey, or questionnaire findings and results
• Accurate classification, e.g. program type, acuity, intensity, and service level of assigned cases
• Document clear and concise case contact summaries and care plan reviews
• Adhere to governing regulatory agencies’ timeline standards for risk assessments/surveys/questionnaires, care plan development, and processes
• Collaborate with contracted agencies and community-based organizations to provide supportive services when needed (Home Health agencies, Outpatient Therapy Units, Meals on Wheels, Recuperative Care, Shelters, Transportation, Adult Day, etc.)
• Coordinate timely care transition from one level of care to another, such as acute to SNF or SNF to home or other living arrangement as the member’s care needs change
• Effectively communicate and educate members about the health care delivery system and health plan benefits and limitations
• Assist members with navigating through the CenCal Health healthcare delivery system
• Empower members by providing community resources, educational materials, and self-managing tools
• Promote wellness and healthy living lifestyles to enhance or maintain physical and mental functional capabilities
• As appropriate, address aging-out requirements and transitional requirements into adulthood in care coordination and care planning activities
• Is the Subject Matter Expert (SME) for CM software/module/system used by the Case Management team
• Be the contact person for complex cases and complaint or conflict resolution
• Handle complex cases without limited supervision and direction
• Act as an intermediary for escalated interdepartmental conflicts
• Able to lead, motivate, and influence staff toward process improvement or program change activities
• Embrace change with a positive attitude and as an opportunity to improve and strengthen operational efficiencies
• Other duties as assigned

Qualifications

Required:

• Comply with HIPAA, Privacy, and Confidentiality laws and regulations
• Demonstrate ongoing ability to perform the basic duties of another non-core Health Services unit
• Excellent written, oral, and interpersonal communication skills
• Professional demeanor
• Demonstrate good multi-task, organizational, and time-management skills
• Possess good computer literacy skills. Proficient in WORD
• Demonstrate basic clinical knowledge of either adult or pediatric 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 health care 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
• Demonstrate proficiency with electronic databases, such as Essette, EPIC, and Oracle to document and summarize findings

  Education and Experience

  Required:

• Completed BS degree or higher
• Current unrestricted California Registered Nurse (RN) and/or Nurse Practitioner
• Evidence of prior responsibilities for leading small group discussions, providing mentorship to new employees, or acting as a representative for the department
• Evidence of active participation in special projects requiring independent assignment and submission of timely deliverables
• A minimum of six (6) months previous experience in a Lead, Supervisory, or other management role OR within six (6) months of appointment to the position, attend a HR approved lead or supervisory training
• Strong organizational skills and excellent verbal and written communication skills
• A minimum of one (1) year experience at CenCal Health proficiently performing the responsibilities of the position. For example, if assigned to CM position, the HPNC III Lead must be proficient in the listed Required Skills/Knowledge/Abilities for HPNCII, Case Management position; OR, two (2) or more years of experience in a Medi-Cal MCO or HMO setting; OR, two (2) or more years of direct experience in program development of disease or case management, population management or other related programs

• Desired:

• 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
• Depending on department assignment:  Three - Five (3-5) years of experience in a health plan or managed care setting
• Knowledge of Medi-Cal and/or Medicare health care 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 as described in the Case Management Society of America
• Understand basic quality improvement and population health concepts, principles, and practices
• Being bilingual in Spanish not required but may be helpful as position may involve interacting with Spanish speaking members.
• Able to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projects
• Understand and apply case management concepts, principles, and practices.