Location: Santa Barbara,CA, USA
Job DetailsJob LocationMain Office - Santa Barbara, CAPosition TypeFull TimeEducation LevelNot Specified - OtherJob CategoryMedical ManagementDescriptionCentral Coast Annual Salary Range: $92,025 - $133,437Job SummaryThe Health Plan Nurse Coordinator II - Adult Care Management - (HPNC II - Adult CM) is at the minimum, a Registered Nurse who is assigned to Care Management program. This position reports to the supervisor/manager of the Adult Care Management Program. The HPNC II - Adult CM will perform care management activities, which may include telephonic case or disease management, care coordination or transition, or a combination of all. Duties and ResponsibilitiesComply with HIPAA, Privacy, and Confidentiality laws and regulationsAdhere to Health Plan and Health Services policies and proceduresBe abreast on clinical knowledge related to disease processesEffectively communicate, verbally and in writing, with providers, members, vendors, and other health care providers and in a timely, respectful and professional mannerFunction as a collaborative member of Health Services' multi-disciplinary medical management teamAssist with new HPNC orientation and trainingIdentify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow upSupport and collaborate with the management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Quality Improvement, Care Coordination, and Care Transition activitiesAs required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job dutiesAdhere to mandated reporting requirements appropriate to professional licensing requirementsComply with regulatory standards of governing agencyBe positive, flexible, and open toward operational changesAttend and actively participate in department meetingsSupport and work collaboratively with the Health Services management team in the implementation and management of UM/CM/DM/QI activitiesActively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member's quality of careKeep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practiceEmbrace innovative care strategies that are build value-based programsCoordinate quality and cost-effective medically necessary, health care services for members receiving CM servicesFacilitate and assist members with accessing careEffectively 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 complianceCollaborate with members, their authorized representative, family or caretaker, primary care provider, and other health care providersWork collaboratively with multidisciplinary teams to assess, coordinate and facilitate the needs of membersDevelop, update, and monitor member-centered, individualized care plans that were developed with the member's input and meet regulatory requirementsConduct timely telephonic assessments, surveys, and questionnaires that meet policies and regulatory standardsAccurate and timely determination of member risk levels based on assessment, survey or questionnaire findings and resultsReview and analyze available data to identify members with high-risk conditions.Collaboratively develop and implement strategic interventions/programs for members with high-risk conditionsProvide educational materials and resource tools based on the member's risk levelAccurate classification, e.g., program type, acuity, intensity, and service level of assigned casesDocument clear and concise case contact summaries and care plan reviewsAdhere to governing regulatory agencies' timeline standards for risk assessments/surveys/questionnaires, care plan development and processesCollaborate 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 changeEffectively communicate and educate members about the health care delivery system and health plan benefits and limitationsAssist members with navigating through CenCal Health healthcare delivery systemEmpower members by providing community resources, educational materials, and self-managing toolsPromote wellness and healthy living lifestyles to enhance or maintain physical and mental functional capabilitiesAssess the care needs of the member, identify interventions, develop care plans, implement and facilitate necessary services, and establish timelines for case management servicesEffectively communicate verbally and in writing with primary care providers and other health care providers involved in the care of the memberAs appropriate, address aging out requirements and transitional requirements into adulthood in care coordination and care planning activitiesAct as the mentor to new HPNCsAssist in orientation and training of new HPNCs in the core unitOther duties as assignedQualificationsKnowledge/Skills/AbilitiesRequired:Bilingual in Spanish for interactions with membersComply with HIPAA, Privacy, and Confidentiality laws and regulationsDemonstrate ongoing ability to perform the basic duties of another non-core Health Services unitExcellent written, oral and interpersonal communication skillsProfessional demeanorDemonstrate good multi-task, organizational, and time-management skillsPossess good computer literacy skills. Proficient in WORDDemonstrate basic clinical knowledge of either adult or pediatric health conditions and disease processes, (depending on assignment)Able to work effectively individually and collaboratively in a cross-functional team environmentAble to communicate professionally by phone, with members and their families, physicians, providers, and other health care providers; in writing, and in-person (in a one-to-one or group setting) and to demonstrate excellent interpersonal communication skillsAble to compose clear, professional, and grammatically correct correspondence to members and providersDemonstrate proficiency with electronic database, such as Essette, EPIC, MedHok, ZeOmega, Meditech to document and summarize findingsAble to meet timelines/deadlines of daily work responsibilities and, as assigned, for long-term projectsUnderstand and apply case management concepts, principles, and practicesDemonstrate proficiency in utilizing CM database and its related software and modulesDemonstrate proficiency in the development, implementation and outcome measurement of Individualized Care Plans (ICP)Evidence that ICPs are developed in a timely manner, clear and concise, member-centric, and have limited changes to goal/outcome completion timelineCategorize cases in the correct program, program type, acuity and intensityProficient understanding of Medi-Cal coverage and limitationsAble to assist in development of needs assessment tools to create value-based CM/DM programs and measure outcomesEducation and ExperienceRequired:Bilingual in Spanish for interactions with membersCurrent active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of 2 years' experience as a RN or NPA minimum of two (2) years' experience in CM or DM in a MCO, HMO, PPO, hospital, clinic or outpatient settingA minimum of one (1) year experience at CenCal Health proficiently performing the responsibilities of the position OR, two (2) or more years of experience in a Medi-Cal MCO or HMO setting.Desired: Certification in case management, or healthcare management, such as CCM, or board certification in area of specialtyPrior CM or DM experience in a managed care setting