Health Plan Nurse Coordinator I - Case Management - Utilization Management Pediatric Program

About the position The Health Plan Nurse Coordinator (HPNC) is a Registered Nurse responsible for supporting the Utilization Management, Case Management, and Pediatric-Whole Child Model Unit. This position reports to the Program Supervisor or an assigned designee. The HPNC in CM/UM Pediatrics performs a range of activities, including telephonic or onsite clinical reviews, case or disease management, care coordination and transitions, population health initiatives, or a combination thereof. Additionally, the HPNC may work within specialized programs, such as Mental/Behavioral Health Services, requiring targeted Utilization Management or Case Management for specific member populations. For roles involving significant member interaction, fluency in Spanish may be required. Responsibilities • Ensure adherence to HIPAA, privacy, and confidentiality regulations. • Follow Health Plan, Medical Management, and Health Services policies and procedures. • Maintain up-to-date clinical knowledge of disease processes. • Communicate effectively, professionally, and respectfully with providers, members, vendors, and healthcare teams both verbally and in writing. • Work as part of a multidisciplinary medical management team. • Identify and report quality of care concerns to management or the appropriate department. • Collaborate with management and team members in implementing Utilization Management (UM), Case Management (CM), Disease Management (DM), Population Health (PH), and care transition initiatives. • Participate in and support quality improvement activities related to job responsibilities. • Embrace operational changes with positivity and flexibility. • Comply with professional licensing requirements, regulatory standards, and governing agency timelines. • Attend and actively engage in departmental meetings. • Coordinate cost-effective, medically necessary services for members. • Facilitate care access and assist members in navigating the healthcare delivery system. • Provide education on health plan benefits, community resources, and self-management tools. • Conduct health screenings, assessments, and planning. • Develop, implement, and monitor individualized, member-centric care plans that meet regulatory requirements. • Perform telephonic assessments, surveys, and risk level determinations in a timely manner. • Review referral and service requests and apply clinical guidelines appropriately. • Perform prospective, concurrent, and retrospective reviews for services and document case summaries concisely. • Compose and issue regulatory-compliant notices of UM decisions. • Conduct on-site reviews of members in hospitals or care facilities. • Perform face-to-face assessments when required, such as using the CBAS assessment tool. • Work with members, families, caregivers, and healthcare providers to assess needs and coordinate services. • Partner with community-based organizations to arrange supportive services. • Coordinate seamless transitions between care levels (e.g., hospital to skilled nursing, skilled nursing to home). • Educate members on wellness and lifestyle practices to maintain or improve physical and mental health. • Document assessments, care plans, and case summaries clearly and accurately. • Ensure adherence to regulatory timelines for risk assessments, surveys, and care plans. • Support innovation in care strategies and value-based program development. • Act as a liaison for UM processes and operational standards. • Address transitional needs for members aging into adulthood as required. • Perform other duties as assigned. Requirements • Maintain a professional demeanor in all interactions. • Exhibit strong multitasking, organizational, and time-management abilities. • Demonstrate clinical knowledge of adult or pediatric health conditions and disease processes, depending on assignment. • Work effectively both independently and collaboratively within cross-functional teams. • Communicate professionally by phone, in writing, and in-person with members, families, physicians, providers, and other healthcare professionals. • Display excellent interpersonal communication skills. • Compose clear, professional, and grammatically correct correspondence for members and providers. • Meet deadlines for daily responsibilities and long-term projects. • Demonstrate proficiency in organizing and managing work assignments. • Understand and apply quality improvement theories, strategies, and methods to achieve rapid-cycle improvement (for Quality Improvement assignments). • Accurately apply and interpret clinical guidelines. • Perform accurate HEDIS medical record abstraction as assigned. • Utilize IT UM databases and electronic clinical guidelines effectively. • Compose accurate and grammatically correct Notices of Action or denial notices, using appropriate templates and citations with minimal errors. • Maintain a thorough understanding of Medi-Cal coverage and limitations. • For Pediatric Department assignments, demonstrate expertise in CCS eligibility and clinical guidelines. • Develop, implement, and measure outcomes of Individualized Care Plans. • Ensure ICPs are timely, concise, member-centric, and goal-focused with minimal timeline adjustments. • Accurately categorize cases by program, type, acuity, and intensity. • Act as a mentor for new Health Plan Nurse Coordinators in Utilization Management and Case Management. • Possess a current, active, and unrestricted California Registered Nurse (RN) or Nurse Practitioner (NP) license. • A minimum of two (2) years of experience in a nursing role. Nice-to-haves • Knowledge of Medi-Cal and/or Medicare benefits, managed care regulations, including contract limitations, delivery, reimbursement systems, and the role of medical management activities. • Understand basic utilization review principles and practices. • Familiarity with case and disease management concepts as outlined by the Case Management Society of America. • Basic knowledge of quality improvement and population health principles. • Certification in case management, utilization management, quality, or healthcare management (e.g., CCM, CMCN, CPHQ, HCQM, CPUM, CPUR) or board certification in a specialty area. • Relevant experience in Utilization Management (UM), Case Management (CM), Disease Management (DM), or Quality Improvement (QI) within a managed care setting, depending on unit assignment. Apply tot his job Apply To this Job