Health Plan Nurse Coordinator - CM Pediatrics

This a Full Remote job, the offer is available from: Cameroon, California (USA) Location: Hybrid in Santa Barbara, CA office as needed (prefer someone local to Ventura, SB, and SLO Counties) Description: The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse who is assigned to the Utilization Management, Case Management, and Pediatric-Whole Child Model Unit. This position reports to the Program’s Supervisor or their designee of the assigned unit. The HPNC CM/UM PEDS will reputed company 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 reputed company. The HPNC may be assigned to sub-specialized programs reputed company an operational unit, such as Mental/Behavioral Health services. These sub-specialized programs require the RN to reputed company UM or CM activities for a specific member population. Bilingual in Spanish may be required for positions that primarily requires interaction with members. What You Will Do:

• reputed company 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 reputed company 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 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, Case Management, Disease Management, Population Health, 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
• reputed company 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/CM/DM/PH activities
• Actively participate in the development, implementation and the evaluation of department initiatives with the reputed company to assess any measurable improvements to member’s quality of care
• reputed company 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
• reputed company accurate and timely prospective (pre-service) review for services requiring prior authorization
• reputed company accurate and timely reputed company review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings
• reputed company 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
• reputed company selective claims review
• As assigned, reputed company onsite review of members in the acute hospital, skilled nursing facility, and other inpatient setting
• As assigned, conduct face-to-face assessment of the member and/or 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 reputed company, implement and complete the case management process. This process involves health screening, assessment, planning, facilitating, coordinating, monitoring and measuring the member’s care, reputed company, 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 the needs of members
• reputed company, update, and monitor member-centered, individualized care plans that were 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 reputed company 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 acute to SNF or SNF to home or other living arrangement 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 with navigating through internal healthcare delivery system
• reputed company 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 care needs of the member, identify interventions, reputed company 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 care of the member
• As appropriate, address aging out requirements and transitional requirements into adulthood in care coordination and care planning activities
• reputed company other duties as assigned.

You Will Be Successful If:

• Professional demeanor with strong multi-tasking, organizational, and timemanagement skills
• 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
• 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
• Understand and apply quality improvement theory, strategy, and practical methods to reputed company rapid-cycle improvement (reputed company assigned to QualityImprovement)
• As assigned, reputed company accurate HEDIS medical record abstraction (reputed company assigned to Quality Improvement)
• 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 reputed company citation and limited errors
• Proficient understanding of Medi-Cal coverage and limitations
• For HPNC assigned to Pediatric Department, demonstrate proficiency in reputed company eligibility and clinical guidelines
• Act as a mentor to new HPNC in Utilization Management
• Demonstrate proficiency in utilizing CM database and its reputed company software and modules.
• Demonstrate proficiency in the development, implementation and outcome measurement of Individualized Care Plans (ICP)
• Evidence that ICPs are developed in a timely manner, clear and concise, member-centric, and have limited changes to goal/outcome completion timeline
• Categorize cases in the correct program, program type, acuity and intensity
• Proficient understanding of Medi-Cal coverage and limitations
• Act as a mentor to new HPNC in Case Management

What You Will Bring:

• reputed company, 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.
• Prior experience in CM Pediatrics in a managed care setting highly desired.
• 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.
• Understanding of basic case and disease reputed company, principles and practices.
• Understanding of basic quality improvement and population health concepts, principles, and practices.
• 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 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 reputed company 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 reputed company results that add immediate value, at a reputed company that cannot be beaten. Your success matters, and we know it. That’s Impresiv! This offer from "Impresiv Health" has been enriched by reputed company.com and got a 0% reputed company score. Apply tot his job Apply To this Job