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Health Plan Nurse Coordinator, Adult UM
This a Full Remote job, the offer is available from: Canada, California (USA)
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 following are the core responsibilities:
- Perform utilization management activities – This is the core overarching responsibility and encompasses all tasks related to managing the appropriate use of healthcare services.
- Conduct telephonic or onsite clinical reviews – This specifies the method of carrying out utilization management, representing a significant function under the broader UM umbrella.
- Coordinate care and manage transitions of care – This refers to ensuring members receive appropriate, continuous, and coordinated care across different healthcare settings.
- Communicate effectively with members, potentially in Spanish – While not always required, this responsibility highlights the importance of member interaction and language proficiency for certain roles.
- Duties related to UM reviews, application of guidelines, and decision-making processes:
- 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.
- Conduct selective claims reviews.
- Apply utilization review principles, practices, and guidelines as appropriate for members in skilled nursing and long-term care facilities.
- As assigned, perform onsite reviews of members in acute hospitals, skilled nursing facilities, and other inpatient settings.
- Compose accurate draft notices of action, non-coverage, or other regulatory-required notices to members and providers regarding UM decisions.
- Document clear and concise case review summaries.
- Apply and cite sources accurately in decision-making processes.
- Adhere to regulatory timelines for processing, reviewing, and completing reviews.
- Support and collaborate with the Medical Management and Health Services management teams in implementing and managing UM activities.
- Serve as a liaison to providers and internal employees regarding UM processes and operational standards.
- Duties related to direct clinical contact and assessments:
- As assigned, conduct face-to-face assessments of members and/or their authorized representatives, family, caregivers, etc., to complete necessary assessments (e.g., CBAS assessment tool).
- As assigned, perform onsite reviews of members in acute hospitals, skilled nursing facilities, and other inpatient settings.
- Conduct accurate and timely reviews (prospective, concurrent, retrospective) as part of clinical decision-making.
- Duties related to cross-setting care continuity and interdisciplinary work:
- Collaborate with management, medical management, and health services teams in the implementation and management of Utilization Management, Care Coordination, and Care Transition activities.
- 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 department for follow-up.
- Actively engage in the development, implementation, and evaluation of department initiatives to assess measurable improvements in member quality of care.
- Embrace innovative care strategies that support value-based programs.
- Duties related to interpersonal communication, professionalism, and regulatory compliance:
- Communicate effectively, both verbally and in writing, with providers, members, vendors, and other healthcare professionals in a timely, respectful, and professional manner.
- Serve as a liaison to providers and internal employees regarding UM processes and operational standards.
- Comply with HIPAA, Privacy, and Confidentiality laws and regulations.
- Adhere to Health Plan, Medical Management, and Health Services policies and procedures.
- Comply with regulatory standards of governing agencies.
- Adhere to mandated reporting requirements according to professional licensing standards.
- Participate as required in the implementation, assessment, and evaluation of quality improvement activities related to job duties.
- Attend and actively participate in department meetings.
- Remain positive, flexible, and open to operational changes.
- Stay informed about healthcare benefits, limitations, regulatory requirements, disease processes, treatment modalities, community care standards, and professional nursing practices.
- Stay current with clinical knowledge related to disease processes.
- Perform other duties as assigned.
You Will Be Successful If:
- 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.
What You Will Bring:
- 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.
- 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.
- 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.
- Prior experience in Utilization Management (UM) within a managed care setting 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!
This offer from "Impresiv Health" has been enriched by Jobgether.com and got a 81% flex score.
