What are the responsibilities and job description for the Health Plan Nurse Coordinator - Adult Utilization Management position at Impresiv Health?
Title : Health Plan Nurse Coordinator - UM Adult
Pay Rate : $47 / hour
Location : Remote - Must live in California
Description : The Health Plan Nurse Coordinator (HPNC) - Adult Utilization management is a Registered Nurse who is 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.
What You Will Do :
- 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 internal 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 internal 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.
You Will Be Successful If :
What You Will Bring :
About Impresiv Health :
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Salary : $47
