Health Care Nurse Coordinator II - Adult CM

Description

Central Coast Annual Salary Range: $92,025 - $133,437

Job Summary

The Health Plan Nurse Coordinator II – Adult Care Management - (HPNC II – Adult CM) is at the minimum, a Registered Nurse who is assigned to Care Management program. This position reports to the supervisor/manager of the Adult Care Management Program. The HPNC II – Adult CM will perform care management activities, which may include telephonic case or disease management, care coordination or transition, or a combination of all.

Duties and Responsibilities

• Comply with HIPAA, Privacy, and Confidentiality laws and regulations

• Adhere to Health Plan and Health Services policies and procedures

• Be abreast on clinical knowledge related to disease processes

• 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 Health Services’ multi-disciplinary medical management team

• Assist with new HPNC orientation and training

• Identify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow up

• Support and collaborate with the management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Quality Improvement, Care Coordination, and Care Transition activities 

• As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates 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 toward operational changes

• Attend and actively participate in department meetings

• Support and work collaboratively with the Health Services management team in the implementation and management of UM/CM/DM/QI activities

• Actively participate in the development, implementation and the 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 are build value-based programs

• Coordinate quality and cost-effective medically necessary, health care services for members receiving CM services

• Facilitate and assist members with accessing care

• 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 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

• Review and analyze available data to identify members with high-risk conditions. 

• Collaboratively develop and implement strategic interventions/programs for members with high-risk conditions

• Provide educational materials and resource tools based on the member’s risk level

• 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 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 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

• Assess the care needs of the member, identify interventions, develop care plans, implement and facilitate necessary services, and establish timelines for case management services

• Effectively communicate verbally and in writing with primary care providers and other health care providers involved in the care of the member

• As appropriate, address aging out requirements and transitional requirements into adulthood in care coordination and care planning activities

• Act as the mentor to new HPNCs

• Assist in orientation and training of new HPNCs in the core unit

• Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

Required:

• Bilingual in Spanish for interactions with members

• 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, (depending on assignment)

• 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 database, such as Essette, EPIC, MedHok, ZeOmega, Meditech to document and summarize findings

• 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

• Demonstrate proficiency in utilizing CM database and its related software and modules

• Demonstrate proficiency in the development, implementation and outcome measurement of Individualized Care Plans (ICP)

• Evidence that ICPs are developed in a timely manner, clear and concise, member-centric, and have limited changes to goal/outcome completion timeline

• Categorize cases in the correct program, program type, acuity and intensity

• Proficient understanding of Medi-Cal coverage and limitations

• Able to assist in development of needs assessment tools to create value-based CM/DM programs and measure outcomes

Education and Experience

Required:

• Bilingual in Spanish for interactions with members

• Current active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of 2 years’ experience as a RN or NP

• A minimum of two (2) years’ experience in CM or DM in a MCO, HMO, PPO, hospital, clinic or outpatient setting

• A minimum of one (1) year experience at CenCal Health proficiently performing the responsibilities of the position OR, two (2) or more years of experience in a Medi-Cal MCO or HMO setting.

Desired:

• Certification in case management, or healthcare management, such as CCM, or board certification in area of specialty

• Prior CM or DM experience in a managed care setting

Salary : $92,025 - $133,437