Health Plan Nurse Coordinator - Adult Case Management

We work with a vast network of dedicated and compassionate doctors, hospitals, pharmacies and other types of providers and facilities that take care of our members. We presently have over 275 Primary care providers and more than 1250 specialists that provide care to our members. They give generously of their time and expertise. We also have a very dedicated board of directors that come from within our community. They donate their time to oversee and ensure the best outcome for our members, and oversee our budget.

We provide health coverage for 1 in 4 people in Santa Barbara County, and 1 in 5 in San Luis Obispo County. We hope you will see our commitment to our community here. CenCal Health is a great place to work, and there is information about joining our team within this section. We have been in operation since 1983, and are recognized nationally as the oldest Medicaid managed care program of its kind in the country.

When assigned to the Case Management (CM) position, in addition to the General Duties and Responsibilities noted above, the HPNC-Case Management responsibilities include, but are not limited to:

• 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 CenCal Health 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

Required:

• Current active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner
• (NP) License with a minimum of two (2) years’ experience as a RN or NP

Desired:

• Certification in case management, utilization, quality, or healthcare management, such as
• CCM, CMCN, CPHQ, HCQM, CPUM, CPUR or board certification in area of specialty
• Depending on unit assignment: Prior UM, CM, DM, or QI experience in a managed care
• setting

All your information will be kept confidential according to EEO guidelines.