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

Central Coast Annual Salary Range: $84,877 - $123,072 

Job Summary

Candidates for this position must reside on the Central Coast (Santa Barbara or San Luis Obispo, Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

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.

Duties and 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.

Knowledge/Skills/Abilities

Required Overall:

• 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.

Desired Overall:

• 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.

Education and Experience

Required:

• 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.

Desired:

• 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.