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Health Plan Nurse Coordinator I

Company

CenCal Health
Address , Santa Barbara, 93110, Ca
Employment type FULL_TIME
Salary $69,681 - $104,522 a year
Expires 2023-06-09
Posted at 1 year ago
Job Description
Job Summary
The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse who is assigned to one of several Health Services’ operational units. This Position will report to the Program Manager or the designee of the Case Management - Adult Programs unit. The HPNC may perform utilization management activities, which may include telephonic or onsite clinical review; case or disease management, care coordination or transition; or population health activities; or a combination of all. 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.
Duties and Responsibilities
  • Attend and actively participate in department meetings.
  • Embrace innovative care strategies that build value-based programs
  • Effectively communicate, verbally and in writing, with providers, members, vendors, and other healthcare providers in a timely, respectful and professional manner.
  • Be positive, flexible, and open to operational changes.
  • 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.
  • Be abreast of clinical knowledge related to disease processes.
  • Comply with regulatory standards of governing agency.
  • Adhere to Health Plan and Health Services policies and procedures.
  • Support and collaborate with the management and health services team members in the implementation and management of CM, PH, UM, Quality Improvement, Care Coordination, and Care Transition activities.
  • Comply with HIPAA, Privacy, and Confidentiality laws and regulations.
  • Adhere to mandated reporting requirements appropriate to professional licensing requirements.
  • Support and work collaboratively with the Health Services management team in the implementation and management of the assigned unit's activities.
  • Actively participate in the development, implementation, and evaluation of department initiatives with the intent to assess any measurable improvements to members' quality of care.
  • Identify and report quality of care concerns to management and, as directed, to the appropriate CenCal Health department for follow-up.
  • Function as a collaborative member of Health Services' multi-disciplinary medical management team.
  • As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job duties.
When assigned to the Case Management (CM) position, in addition to the General Duties and Responsibilities noted above, the HPNC-Case Management responsibilities include, but are not limited to:
  • 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 member's input and meet regulatory requirements.
  • Coordinate timely care transition from one level of care to another, such acute to SNF, SNF to home, or other living arrangements as the member's care needs change.
  • Document clear and concise case contact summaries and care plan reviews.
  • Effectively communicate verbally and in writing with primary care providers and other health care providers involved in the care of the member.
  • Coordinate quality and cost-effective medically necessary health care services for members receiving CM services.
  • Other duties as assigned
  • 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.).
  • Assess the care needs of the member, identify interventions, develop care plans, implement and facilitate necessary services, and establish timelines for case management services.
  • Assist members with navigating through CenCal Health healthcare delivery system.
  • Effectively and efficiently implement and complete the case management process. This process involves health screening, assessment, planning, facilitating, coordinating, monitoring, and measuring the member's care, progress, and compliance.
  • Promote wellness and healthy living lifestyles to enhance or maintain physical and mental functional capabilities.
  • Facilitate and assist members with accessing care.
  • Adhere to governing regulatory agencies' timeline standards for risk assessments/surveys/questionnaires, care plan development, and processes.
  • 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.
  • Conduct timely telephonic assessments, surveys, and questionnaires that meet policies and regulatory standards.
  • Collaborate with members, their authorized representative, family or caretaker, primary care provider, and other health care providers.
  • As appropriate, address aging-out requirements and transitional requirements into adulthood in care coordination and care planning activities.
  • Empower members by providing community resources, educational materials, and self-managing tools.
  • Effectively communicate and educate members about the health care delivery system and health plan benefits and limitations.
Education and Experience
Required:
  • Current active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years experience as an RN or NP
Desired:
  • Depending on unit assignment: Prior UM, CM, DM, or QI experience in a managed care setting
  • 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

Additional Information

Schedule:

  • Remote
  • Monday to Friday

Benefits:

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