Title: Health Plan Nurse Coordinator - UM Adult

Schedule: Hybrid, may be required to be in office a few days a year

Location: Must be local from San Jose to Ventura County, CA

Description: The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse who is assigned the Utilization Management. This position reports to the Program's Manager or their designee of the assigned unit. The HPNC will perform utilization management activities, which may include telephonic or onsite clinical review; care coordination or transition, or a combination of all. Bilingual in Spanish may be required for positions that primarily requires interaction with members.

What You Will Do:

Comply with HIPAA, Privacy, and Confidentiality laws and regulations
Adhere to Health Plan, Medical Management and Health Services policies and procedures
Be abreast on clinical knowledge related to disease processes
Effectively communicate, verbally and in writing, with providers, members, vendors, and other health care providers and in a timely, respectful and professional manner
Function as a collaborative member of Medical Management/Health Services' multi-disciplinary medical management team
Identify and report quality of care concerns to management and as directed, to the appropriate department for follow up
Support and collaborate with the management, medical management and health services team members in the implementation and management of Utilization Management, Care Coordination, and Care Transition activities
As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates 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 toward operational changes
Attend and actively participate in department meetings
Support and work collaboratively with the Medical Management and Health Services management team in the implementation and management of UM/ activities
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
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 are build value-based programs
Act as a liaison primarily to providers and employees regarding UM processes and its operational standards
Timely review of request for referrals and services
Application and interpretation of established clinical guidelines and/or benefits limitations
Accurate decision-making skills to support the appropriateness and medical necessity of requested services
Perform accurate and timely prospective (pre-service) review for services requiring prior authorization
Perform accurate and timely concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings
Perform accurate and timely retrospective (post-service) review for services that required prior authorization but was not obtained by the provider before rendering services
Document clear and concise case review summaries
Compose appropriate and accurate draft notice 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
Other duties as assigned

You Will Be Successful If:

Demonstrate professional demeanor
Demonstrate strong multi-tasking, organizational, and time-management skills
Demonstrate clinical knowledge of adult or health conditions and disease processes
Able to work effectively individually and collaboratively in a cross-functional team environment
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 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
Demonstrate ability to accurately apply and interpret clinical guidelines
Demonstrate proficiency in organizing and managing work assignment
Demonstrate proficiency in utilizing IT UM database and electronic clinical guidelines
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
Proficient understanding of Medi-Cal coverage and limitations
Act as a mentor to new HPNC in Utilization Management

What You Will Bring:

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
Knowledge of Medi-Cal and Medicare health benefits, managed care regulations, benefits, contract limitations, deliver and reimbursement systems, and medical management activities required.
Previous experience working in managed care UM department or with an MCO
Previous experience completing Assessments and building Individual Care Plans
Certifications in case management, utilization, quality preferred (CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, etc.)
Bilingual in Spanish preferred

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv!

Health Plan Nurse Coordinator

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