Title: Health Plan Nurse Coordinator - Enhanced Care Management

Location: Remote, may be needed in Santa Barbara, CA office 1x a month

Description: Our client is looking for a Health Plan Nurse Coordinator (RN) to support their enhanced care management team. The HPNC performs utilization management activities, which may include telephonic or onsite clinical review; care coordination or transition of care for support for Members eligible for ECM. The HPNC-ECM serves as a supportive resource for ECM providers regarding authorization processing, ECM Core services, and plan benefits, aiming to support Members in ECM.

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.
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.
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.
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.
Perform Utilization Management duties, (See Utilization Management Responsibilities).
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 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.
Conduct chart audits to ensure ECM providers are providing the core components of ECM: outreach initiatives, comprehensive assessment/s, care plans, interventions, outreach documentation, and obtaining releases of information.
Collaborate with ECM Program Manager to develop of audit tools, report templates or other ECM forms/documents as requested.
Attend ECM care coordination meetings, as needed.
Responsible for assisting with transitioning members from ECM to lower level of care management in collaboration with ECM providers.
Participate in meetings/committees related to ECM.
Other duties as assigned

You Will Be Successful If:

Professional demeanor.
Demonstrate strong multi-tasking, organizational, and time-management skills.
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 exceptional research, planning, problem-solving, critical thinking, and attention to detail.
Demonstrate ability to understand and apply ECM criteria during related to audits and utilization management duties.
Proficient understanding of Medi-Cal coverage and limitations.
Demonstrate proficiency in care management activities such as assessment completion, care plan development, monitoring and follow up.
Demonstrate ability to work directly and collaboratively with ECM providers, members and internal departments.
Act as a mentor to new HPNC in Enhanced Care Management.

What You Will Bring:

Current and unrestricted California RN License
Prior UM/CM experience in a managed care setting.
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.
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 - ECM

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