Health Plan Nurse Coordinator I - Behavioral Health

Annual Salary Range: $69,681 - $104,522

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Job Summary

The Health Plan Nurse Coordinator Behavioral Health (HPNC-BH) is a Registered Nurse who is assigned to the Behavioral Health Department.

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The candidate selected for this full-time remote position will have a current active unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) license and a minimum of two (2) years of nursing experience.

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This position reports to the Behavioral Health Operations Manager and will have responsibilities for utilization management activities, which may include but are not limited to telephonic or onsite clinical review; case management, care coordination or transition, or population health activities; or a combination of all.

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Regular attendance is essential to perform this job.

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Duties and Responsibilities

• Accurate decision-making skills to support the appropriateness and medical necessity of requested services.
• Accurate application and citation of sources used in decision-making.
• 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.
• Attend and actively participate in department meetings.
• Comply with regulatory standards of governing agency.
• Perform selective claims review.
• Application and interpretation of established clinical guidelines and/or benefits limitations
• Timely review of request for referrals and services
• Adhere to Health Plan, Medical Management and Health Services policies and procedures.
• Other duties as assigned.
• Identify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow up.
• Perform accurate and timely review for services.
• Be abreast on clinical knowledge related to mental health, psychological testing, neuropsychological testing, behavioral health treatment, county mental health and DSM diagnosis.
• Embrace innovative care strategies that are build value-based programs.
• Be positive, flexible, and open toward operational changes.
• Effectively communicate, verbally and in writing, with providers, members, vendors, and other health care providers and in a timely, respectful, and professional manner
• Complete crisis and risk screening as part of a clinical triage team.
• Adhere to regulatory timeline standards for processing, reviewing, and completing reviews.
• Act as a liaison primarily to providers and CenCal employees regarding UM processes and its operational standards
• Adhere to mandated reporting requirements appropriate to professional licensing requirements.
• 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.
• Apply utilization review principles, practices, and guidelines as appropriate to members in skilled nursing and long-term care facilities.
• Function as a collaborative member of Medical Management/Health Services’ multi-disciplinary medical management team
• Comply with HIPAA, Privacy, and Confidentiality laws and regulations.
• As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job duties.
• Compose appropriate and accurate draft notice of action, non-coverage, or other regulatory required notices to members and providers regarding UM decisions.
• Actively participate in the development, implementation, and the evaluation of department initiatives with the intent to assess any measurable improvements to member’s quality of care.

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Knowledge/Skills/Abilities

Required Overall:

• Able to work effectively individually and collaboratively in a cross-functional team environment.
• Demonstrate clinical knowledge of either adult or pediatric health conditions and disease processes.
• Able to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projects.
• Demonstrate proficiency in utilizing IT UM database and electronic clinical guidelines.
• Demonstrate ability to accurately apply and interpret clinical guidelines.
• Demonstrate strong multi-tasking, organizational, and time-management skills.
• Demonstrate proficiency in organizing and managing work assignment.
• Able to compose clear, professional, and grammatically correct correspondence to members and providers.
• Proficient understanding of Medi-Cal coverage and limitations
• Act as a mentor to new HPNCs in Behavioral Health
• 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 grammatically correct Notice of Actions or other denial notices using the correct notice type and template with accurate source citation and limited errors.
• Demonstrate proficiency in CCS eligibility and clinical guidelines.
• Professional demeanor

Desired Overall:

• Understand basic quality improvement and population health concepts, principles, and practices.
• Understand basic case and disease management concepts, principles and practices as described in the Case Management Society of America
• Understand basic utilization review principles and practices.
• 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

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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 nursing experience.
• 1-2 years of experience in crisis or risk assessment or case management
• 1 year minimum in behavioral health setting or experience in a behavioral health utilization management or working with members with mental health diagnosis.

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

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Additional Information:

Benefits:

• Paid Time Off
• Comprehensive medical, dental, vision & life insurance
• Ten (10) paid holidays per year
• Pension Plan
• Professional Development and Wellness Benefits