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Form of workJob Description
Title: Health Plan Nurse Coordinator (Peds)
Duration: Temporary until 7/31/24
Compensation: $35.50 - $57.28/hour
Description: Our client is looking for a Health Plan Nurse Coordinator (RN) to support their CCS (California Children's Services) team.
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.
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.
Embrace innovative care strategies that build value-based programs.
Act as a liaison primarily to providers and employees regarding UM processes and operational standards.
Timely review of requests for referrals and services
Application and interpretation of established clinical guidelines and benefits limitations.
Accurate decision-making skills to support the appropriateness and medical necessity of requested services.
Document clear and concise case review summaries.
Perform selective claims review.
As assigned, perform on-site reviews of members in the acute hospital, skilled nursing facility, and other inpatient settings.
As assigned, conduct a face-to-face assessment of the member 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, and planning.
Facilitating, coordinating, monitoring, and measuring the member's care, progress, and compliance
Develop, update, and monitor member-centered, individualized care plans 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 as acute care to SNF or SNF to home or other living arrangements, 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 in navigating the 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 member's care needs, identify interventions, develop care plans, implement and facilitate necessary services, and establish timelines for case management services.
As appropriate, address aging-out and transitional requirements into adulthood in care coordination and care planning activities.
Other duties as assigned
You Will Be Successful If:
You understand "whole person "person centered case management
You possess knowledge of community-based resources such as transportation, food banks, mental health, resource centers, parent support centers (Jack's Helping Hand, Alpha Resource Center, Parents Helping Parents, etc.)
You have a thorough understanding of Utilization Management processes and turnaround times
You have a customer service mindset, with great phone etiquette
You have a professional demeanor and can work effectively and collaboratively with cross-functional teams
You demonstrate clinical knowledge of pediatric health conditions and disease processes
You are an excellent communicator in writing, in person, and over the phone with members and their families, physicians, and other healthcare providers
You have a thorough understanding of basic utilization review principles, primary case and disease management, quality improvement, and population health
You are a strong multitasker with a high degree of organizational and time managements skills and can demonstrate proficiency in organizing and managing work assignments.
Demonstrate proficiency in CM database software
Demonstrate proficiency in the development, implementation, and outcome measurements of Individualized Care Plans (ICP)
Proficient in Medi-Cal coverage and limitations
What You Will Bring:
Current and unrestricted California RN License
2+ years of experience in Pediatric Case 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 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!
