Health Plan Nurse Coordinator I - Adult Programs UM
Job DetailsJob LocationMain Office - Santa Barbara, CARemote TypeFully RemoteDescriptionJob SummaryAt the direction of the Utilization Management Supervisor in Adult Programs, the candidate selected for this Health Plan Nurse Coordinator I (HPNC I) part-time position will have responsibilities which include, but are not limited to:
telephonic clinical review; case or disease management; care coordination or transition or population health activities; or a combination of all.
coordinating member discharge planning with their healthcare needs.
corresponding with providers over the phone.
conducting clinical reviews for medical necessity and the appropriate level of care for patients; reviews what care is required for patients needs and meets the criteria for medical necessity.
meeting regulatory timeframes set for utilization management.
The HPNC I is at the minimum, a Registered Nurse with a current active unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) license.
HPNCs are assigned to one of several Health Services operational units.
These units include, but are not limited to, the Utilization Management (UM), Case Management (CM), Disease Management (DM), Pediatric-Whole Child Model (Peds), and Quality Improvement (QI) programs.
The HPNC I may be assigned to sub-specialized programs within an operational unit, such as Mental/Behavioral Health services.
These sub-specialized programs require the RN to perform UM or CM activities for a specific member population.
Regular attendance is essential to perform this job.
Duties and Responsibilities Comply with HIPAA, Privacy, and Confidentiality laws and regulations Adhere to Health Plan, Medical Management 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 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 Support and collaborate with the management, medical management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Population Health, 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 Medical Management and Health Services management team in the implementation and management of UM/CM/DM/PH activities Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to members 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 Other duties as assigned When assigned to the Utilization Management (UM) position, in addition to the General Duties and Responsibilities noted above, the HPNC-Utilization Management responsibilities include, but are not limited to:
Act as a liaison primarily to providers and CenCal employees regarding UM processes and its operational standards Timely review of request for referrals and services 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 concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings 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 As assigned, perform onsite review of members in the acute hospital, skilled nursing facility, and other inpatient setting As assigned, conduct face-to-face assessment of the member and/or with their authorized representative, family, caregiver, etc.
to complete necessary assessments, such as the Community-Based Adult Services (CBAS) assessment tool Other duties as assigned QualificationsSkills/Knowledge/AbilitiesRequired:
Professional demeanor Demonstrate strong multi-tasking, organizational, and time-management skills Demonstrate clinical knowledge of adult 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 an 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 For HPNC I Utilization Management:
Demonstrate ability to accurately apply and interpret clinical guidelines Demonstrate proficiency in organizing and managing work assignment Demonstrate proficiency in utilizing IT UM database and electronic clinical guidelines Able to compose grammatically correct Notice of Actions or other denial notices using the correct notice type and template with accurate source citation and limited errors Proficient understanding of Medi-Cal coverage and limitations Act as a mentor to new HPNC in Utilization Management Desired Overall:
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 and ExperienceRequired:
Current active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of 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 Prior UM experience in a managed care setting Additional Information:
Schedule:
Part-time remote position 20
hours per week
Benefits:
Pension Plan Professional Development and Wellness Benefits Alternative Transportation Incentives Comprehensive medical, dental, vision & life insurance Paid Time Off Ten (10) paid holidays per year Recommended Skills Assessments Behavioral Medicine Care Coordination Case Management Certified Case Manager Certified Nurse Practitioner Estimated Salary: $20 to $28 per hour based on qualifications.
telephonic clinical review; case or disease management; care coordination or transition or population health activities; or a combination of all.
coordinating member discharge planning with their healthcare needs.
corresponding with providers over the phone.
conducting clinical reviews for medical necessity and the appropriate level of care for patients; reviews what care is required for patients needs and meets the criteria for medical necessity.
meeting regulatory timeframes set for utilization management.
The HPNC I is at the minimum, a Registered Nurse with a current active unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) license.
HPNCs are assigned to one of several Health Services operational units.
These units include, but are not limited to, the Utilization Management (UM), Case Management (CM), Disease Management (DM), Pediatric-Whole Child Model (Peds), and Quality Improvement (QI) programs.
The HPNC I may be assigned to sub-specialized programs within an operational unit, such as Mental/Behavioral Health services.
These sub-specialized programs require the RN to perform UM or CM activities for a specific member population.
Regular attendance is essential to perform this job.
Duties and Responsibilities Comply with HIPAA, Privacy, and Confidentiality laws and regulations Adhere to Health Plan, Medical Management 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 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 Support and collaborate with the management, medical management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Population Health, 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 Medical Management and Health Services management team in the implementation and management of UM/CM/DM/PH activities Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to members 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 Other duties as assigned When assigned to the Utilization Management (UM) position, in addition to the General Duties and Responsibilities noted above, the HPNC-Utilization Management responsibilities include, but are not limited to:
Act as a liaison primarily to providers and CenCal employees regarding UM processes and its operational standards Timely review of request for referrals and services 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 concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings 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 As assigned, perform onsite review of members in the acute hospital, skilled nursing facility, and other inpatient setting As assigned, conduct face-to-face assessment of the member and/or with their authorized representative, family, caregiver, etc.
to complete necessary assessments, such as the Community-Based Adult Services (CBAS) assessment tool Other duties as assigned QualificationsSkills/Knowledge/AbilitiesRequired:
Professional demeanor Demonstrate strong multi-tasking, organizational, and time-management skills Demonstrate clinical knowledge of adult 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 an 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 For HPNC I Utilization Management:
Demonstrate ability to accurately apply and interpret clinical guidelines Demonstrate proficiency in organizing and managing work assignment Demonstrate proficiency in utilizing IT UM database and electronic clinical guidelines Able to compose grammatically correct Notice of Actions or other denial notices using the correct notice type and template with accurate source citation and limited errors Proficient understanding of Medi-Cal coverage and limitations Act as a mentor to new HPNC in Utilization Management Desired Overall:
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 and ExperienceRequired:
Current active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of 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 Prior UM experience in a managed care setting Additional Information:
Schedule:
Part-time remote position 20
hours per week
Benefits:
Pension Plan Professional Development and Wellness Benefits Alternative Transportation Incentives Comprehensive medical, dental, vision & life insurance Paid Time Off Ten (10) paid holidays per year Recommended Skills Assessments Behavioral Medicine Care Coordination Case Management Certified Case Manager Certified Nurse Practitioner Estimated Salary: $20 to $28 per hour based on qualifications.
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