Health Plan Nurse Coor. UM Adult (Talent Pipeline)

Description

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Central Coast Salary Range: $84,877 - $123,072 Annually

Job Summary

The Health Plan Nurse Coordinator – Adult Utilization Management (HPNC – Adult UM) is a Registered Nurse 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.

Duties and Responsibilities

• 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 CenCal Health 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 CenCal 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.

Qualifications

Knowledge/Skills/Abilities

Required

• Professional demeanor.

• Strong multi-tasking, organizational, and time-management skills.

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• Clinical knowledge of adult or pediatric health conditions and disease processes.

• Ability to work effectively both individually and collaboratively in a cross-functional team environment.

• Excellent communication skills, both verbal and written, with members, their families, physicians, providers, and other healthcare professionals in a professional manner (via phone, in writing, and in-person).

• Ability to compose clear, professional, and grammatically correct correspondence to members and providers.

• Ability to meet deadlines and manage daily work responsibilities, as well as long-term projects.

• Skill in accurately applying and interpreting clinical guidelines.

• Proficiency in organizing and managing work assignments.

• Proficiency in utilizing IT UM databases and electronic clinical guidelines.

• Ability to compose grammatically correct Notices of Action or other denial notices using the correct templates, with accurate source citations and minimal errors.

• Strong understanding of Medi-Cal coverage and limitations.

• For HPNC assigned to Pediatric Department: proficiency in CCS eligibility and clinical guidelines.

• Ability to mentor new HPNCs in Utilization Management.

Desired:

• Knowledge of Medi-Cal and/or Medicare healthcare benefits, managed care regulations, including benefits and contract limitations, delivery and reimbursement systems, and the role of medical management activities.

• Understanding of basic utilization review principles and practices.

Education and Experience

Required:

• Current, active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years of 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 an area of specialty.

• Prior experience in Utilization Management (UM) within a managed care setting.

Salary : $84,877 - $123,072