Job Summary

The Health Plan Nurse Coordinator Enhanced Care Management- (HPNC ECM) is a Registered Nurse who is assigned to Enhanced Care Management unit. The HPNC performs utilization management activities, which may include telephonic or onsite clinical review; care coordination or transition of care for support for Members eligible for ECM. The HPNC-ECM serves as a supportive resource for ECM providers regarding authorization processing, ECM Core services, and plan benefits, aiming to support Members in ECM. Bilingual in Spanish may be required for positions that primarily requires interaction with members.

Duties & Responsibilities

• Comply with HIPAA, Privacy, and Confidentiality laws and regulations
• Adhere to Health Plan, Medical Management and Health Services policies and procedures
• Effectively communicate, verbally and in writing, with providers, members, vendors, and other health care 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
• 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
• 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 are build value-based programs
• Perform Utilization Management duties, (See Utilization Management Responsibilities)
• 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 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
• Conduct chart audits to ensure ECM providers are providing the core components of ECM: outreach initiatives, comprehensive assessment/s, care plans, interventions, outreach documentation, and obtaining releases of information.
• Collaborate with ECM Program Manager to develop of audit tools, report templates or other ECM forms/documents as requested
• Attend ECM care coordination meetings, as needed.
• Responsible for assisting with transitioning members from ECM to lower level of care management in collaboration with ECM providers.
• Participate in meetings/committees related to ECM
• Other duties as assigned

Knowledge/Skills/Abilities

Required:

• Professional demeanor
• Demonstrate strong multi-tasking, organizational, and time-management skills
• 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
• Able to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projects
• Demonstrate exceptional research, planning, problem-solving, critical thinking, and attention to detail.
• Demonstrate ability to understand and apply ECM criteria during related to audits and utilization management duties
• Proficient understanding of Medi-Cal coverage and limitations
• Demonstrate proficiency in care management activities such as assessment completion, care plan development, monitoring and follow up
• Demonstrate ability to work directly and collaboratively with ECM providers, members and internal CenCal Health departments.
• Act as a mentor to new HPNC in Enhanced Care Management

Desired:

• 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

Education & 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
• Depending on unit assignment: Prior UM, CM, DM, or QI experience in a managed care setting

To apply: https://www.paycomonline.net/v4/ats/web.php/jobs/ViewJobDetails?job=191955&clientkey=596BEB0B80DDF299C4E06A78967BCA73

Job Types: Full-time, Permanent

Pay: $82,165.00 - $119,140.00 per year

Benefits:

• 401(k)
• Dental insurance
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Professional development assistance
• Retirement plan
• Vision insurance

Medical specialties:

• Home Health
• Hospice & Palliative Medicine
• Medical-Surgical
• Primary Care
• Public Health

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Experience:

• Nursing: 2 years (Required)

License/Certification:

• BLS Certification (Preferred)
• RN (Required)

Ability to Commute:

• Santa Barbara, CA 93110 (Required)

Ability to Relocate:

• Santa Barbara, CA 93110: Relocate before starting work (Required)

Work Location: Hybrid remote in Santa Barbara, CA 93110