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Health Plan Nurse Coordinator I - UM Pediatric Program

Company: Cencal Health
Location: Santa Barbara
Posted on: May 27, 2023

Job Description:

Job Details
Job Location
Main Office - Santa Barbara, CA
Remote Type
Fully Remote
Position Type
Full Time
Job Category
Medical Management
Salary Range: $69,681 - $104,522
Job Overview
At the direction of the Utilization Management Supervisor in our Pediatric Program, the candidate selected for this Health Plan Nurse Coordinator I (HPNC I) full-time remote position will perform utilization management activities and have responsibilities which include, but are not limited to:

  • Conducting clinical reviews for medical necessity and the appropriate level of care for Pediatric patients; reviews what care is required for patients needs and meets the criteria for medical necessity
  • Meeting regulatory timeframes set for utilization management
  • Corresponding with providers over the phone
  • Coordinating member discharge planning with their healthcare needs
  • Telephonic clinical review; case or disease management; care coordination or transition, or population health activities; or a combination of all 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 with two (2) years of nursing experience. 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), Enhanced Care Management (ECM), Disease Management (DM), Pediatric-Whole Child Model (Pediatric), and Population Health (PH) programs.
    When assigned to the Pediatric Department, the above HPNC Utilization Management activities are limited to members under the age of 21.
    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. Bilingual in Spanish may be required for positions that primarily requires interaction with members.
    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 UM, CM, DM, PH, 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
    • 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
    • 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 members 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 members 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
    • 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 members 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
    • Other duties as assigned When assigned to the Pediatric Department, the above HPNC UM activities are limited to members under the age of 21.
      • Professional demeanor
      • For HPNC assigned to Pediatric Department, demonstrate proficiency in CCS eligibility and clinical guidelines
      • Demonstrate strong multi-tasking, organizational, and time-management skills
      • Demonstrate 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
      • Able to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projects
      • 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
      • 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
      • Act as a mentor to new HPNC in Case 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 Experience
          • 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 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

Keywords: Cencal Health, Santa Barbara , Health Plan Nurse Coordinator I - UM Pediatric Program, Healthcare , Santa Barbara, California

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