Health Plan Nurse Coor. UM Adult (Talent Pipeline)

CenCal Health • Santa Barbara, CA

234d • $84,877 - $123,072

About The Position

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.

Requirements

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

Nice To Haves

• 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.
• For HPNC assigned to Pediatric Department: proficiency in CCS eligibility and clinical guidelines.
• Ability to mentor new HPNCs in Utilization Management.

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.

Benefits

• Salary Range: $84,877 - $123,072 Annually

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 251-500 employees