Health Plan Nurse Coordinator - Adult Utilization 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.

The Health Plan Nurse Coordinator (HPNC) is a Licensed Vocational Nurse or a Registered Nurse who is assigned to one of several Health Services’ operational units. These units include, but are not limited to, the Utilization Management, Case Management, Disease Management, Pediatric-Whole Child Model, and Population Health programs. This position reports to the Program’s Manager or their designee of the assigned unit. Depending on unit assignment, the HPNC may perform utilization management activities, which may include telephonic or onsite clinical review; case or disease management, care coordination or transition, or population health activities; or a combination of all. The HPNC may be assigned to sub-specialized programs within an operational unit, such as Mental/Behavioral Health services. These sub-specialized programs require the RN to perform UM or CM activities for a specific member population. Bilingual in Spanish may be required for positions that primarily requires interaction with members.

• When assigned to the Utilization Management (UM) position, in addition to the General Duties and Responsibilities noted above, the HPNC-Utilization Management responsibilities include, but are not limited to:
• Act as a liaison primarily to providers and CenCal employees regarding UM processes and its operational standards
• Timely review of request for referrals and services
• 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 concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care settings
• 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
• As assigned, perform onsite review of members in the acute hospital, skilled nursing facility, and other inpatient setting
• As assigned, conduct face-to-face assessment of the member and/or with their authorized representative, family, caregiver, etc. to complete necessary assessments, such as the Community-Based Adult Services (CBAS) assessment tool
• Other duties as assigned

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