California Annual Salary Range: $82,165 - $119,140

Job Summary

The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse assigned to theUtilization Management and Case Management units. This position reports to the Program Manager or the designee of the assigned unit. Depending on unit assignment, the HPNC may perform utilization management activities, including telephonic or onsite clinical review, case or disease management, care coordination or transition, population health activities, or a combination. The HPNC 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 primarily requiring member interaction.

Duties and Responsibilities

• General Duties and Responsibilities of the Health Plan Nurse Coordinator (HPNC):

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

• Adhere to Health Plan, Medical Management, and Health Services policies and procedures.

• Be abreast of clinical knowledge related to disease processes.

• Effectively communicate, verbally and in writing, with providers, members, vendors, and other healthcare providers in a timely, respectful, and professional manner.

• Function as a collaborative member of Medical Management/Health Services' multidisciplinary medical management team

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

• Support and collaborate with management, medical management, and health services team members in implementing and managing Utilization Management, Case Management, Disease Management, Population Health, Care Coordination, andCare Transitionactivities in Transition Care Services.

• As required, actively implement, assess, and evaluate quality improvement activities related 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 to operational changes.

• Attend and actively participate in department meetings.

• Support and work collaboratively with the Medical Management and Health Services management team in implementing and managing UM/CM/DM/PH activities.

• Actively participate in developing, implementing, and evaluating department initiatives 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 build value-based programs.

• Act as a liaison primarily to providers and CenCal employees regarding UM processes and operational standards.

• Timely review of requests for referrals and services

• Application and interpretation of established clinical guidelines and benefits limitations.

• Accurate decision-making skills to support the appropriateness and medical necessity of requested services.

• Perform accurate and timely perspective (pre-service) reviews for services requiring prior authorization.

• Perform accurate and timely concurrent reviews for inpatient care in acute care, subacute, skilled nursing, and long-term care settings.

• Perform accurate and timely retrospective (post-service) reviews for services that required prior authorization but were not obtained by the provider before rendering services.

• Document clear and concise case review summaries.

• Compose appropriate and accurate draft notices 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 on-site reviews of members in the acute hospital, skilled nursing facility, and other inpatient settings.

• As assigned, conduct a face-to-face assessment of the member 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, and 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 members' needs.

• Develop, update, and monitor member-centered, individualized care plans 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.

• 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 as acute care to SNF or SNF to home or other living arrangements, 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 in navigating the 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 member's care needs, 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 member's care.

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

• Other duties as assigned.

Knowledge/Skills/Abilities

Required Overall:

• Professional demeanor

• 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.

• Ability 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.

• Understand and apply quality improvement theory, strategy, and practical methods to achieve rapid-cycle improvement (when assigned to Quality Improvement)

• As assigned, perform accurate HEDIS medical record abstraction (when assigned to Quality Improvement)

• Demonstrate ability to apply and interpret clinical guidelines accurately.

• Demonstrate proficiency in organizing and managing work assignments.

• Demonstrate proficiency in utilizing the IT UM database and electronic clinical guidelines.

• Able to compose grammatically correct Notice of Actions or other denial notices using the proper notice type and template with accurate source citations and limited errors.

• Proficient understanding of Medi-Cal coverage and limitations

• For HPNC assigned to the Pediatric Department, demonstrate proficiency in CCS eligibility and clinical guidelines.

• Act as a mentor to new HPNC in Utilization Management

• Demonstrate proficiency in utilizing the 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 promptly, clear and concise, member-centric, and have limited goal/outcome completion timeline changes.

• Categorize cases using the correct program type, acuity, and intensity.

• Proficient understanding of Medi-Cal coverage and limitations

• Act as a mentor to new HPNC in Case Management

Desired Overall:

• Knowledge of Medi-Cal and 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 primary case and disease management concepts, principles, and practices described in the Case Management Society of America.

• Understand essential quality improvement and population health concepts, principles, and practices.

Education and Experience

Required:

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

• Depending on unit assignment: Prior UM, CM, DM, or QI experience in a managed care setting