Health Plan Nurse Coordinator - Pediatrics

Title: Health Plan Nurse Coordinator - Pediatrics

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 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. Bilingual in Spanish may be required for positions that primarily requires interaction with members.

Location: Must be local to Ventura County to Santa Cruz, CA

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 healthcare providers in a timely, respectful, and professional manner.
• Function as a collaborative member of Medical Management/Health Services' multidisciplinary 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 management, medical management, and health services team members in implementing and managing Utilization Management, Case Management, Disease Management, Population Health, Care Coordination, and Care Transition activities in Transition Care Services.
• 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.
• Attend and actively participate in department meetings.
• Actively participate in developing, implementing, and evaluating department initiatives 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.
• Comply with regulatory standards of governing agency.
• Be positive, flexible, and open toward operational changes.
• 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.
• As assigned, perform 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 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.
• 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.
• Develop, 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 when 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 the client's healthcare delivery system.
• Empower 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, develop 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.
• Other duties as assigned.

You Will Be Successful If:

• Professional demeanor.
• Demonstrate strong multi-tasking, organizational, and time-management skills.
• Demonstrate clinical knowledge of pediatric 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.
• Demonstrate proficiency in CCS eligibility and clinical guidelines.
• Demonstrate proficiency in utilizing CM database and its related 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.
• 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.
• Understand basic utilization review principles and practices.
• Understand basic case and disease management concepts, principles and practices as described in the Case Management Society of America.
• Understand basic quality improvement and population health concepts, principles and practices.

What You Will Bring:

• Current and unrestricted California RN License
• 2+ years of experience in Pediatric Case Management/Utilization Management
• Previous experience working in managed care or with an MCO
• Proficiency in CCS eligibility and clinical guidelines
• Previous experience completing Assessments and building Individual Care Plans
• Knowledge of Medi-Cal and Medicare health benefits, managed care regulations, benefits, contract limitations, deliver and reimbursement systems, and medical management activities
• Certifications in case management, utilization, quality highly preferred (CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, etc.)
• Bilingual in Spanish highly 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!