Health Plan Nurse Coordinator - Enhanced Care Management

Location : Remote, may be needed in Santa Barbara, CA as needed

Description :

The Health Plan Nurse Coordinator - Enhanced Care Management (HPNC-ECM) is a Registered Nurse assigned to the Enhanced Care Management unit. This role involves performing utilization management activities, including telephonic or onsite clinical reviews, care coordination, and transition of care support for Members eligible for ECM. The HPNC-ECM acts as a resource for ECM providers, offering guidance on authorization processes, ECM core services, and plan benefits to support Members effectively. Proficiency in Spanish may be required for positions involving frequent interaction with members.

What You Will Do :

• Ensure compliance with HIPAA, privacy, and confidentiality laws and regulations.
• Adhere to Health Plan, Medical Management, and Health Services policies and procedures.
• Communicate effectively, both verbally and in writing, with providers, members, vendors, and other healthcare professionals in a timely, respectful, and professional manner.
• Collaborate as an integral member of the Medical Management / Health Services multidisciplinary team.
• Identify and report quality-of-care concerns to management and escalate to the appropriate department as directed.
• Fulfill mandated reporting requirements in accordance with professional licensing standards.
• Maintain compliance with regulatory standards set by governing agencies.
• Demonstrate positivity, flexibility, and openness to operational changes.
• Actively attend and participate in department meetings.
• Stay informed about healthcare benefits, regulatory requirements, disease processes, treatment modalities, community standards of care, and professional nursing practices.
• Embrace and implement innovative care strategies that support value-based programs.
• Perform utilization management duties, including but not limited to those listed under Utilization Management Responsibilities.
• Interpret and apply established clinical guidelines and benefit limitations appropriately.
• Utilize accurate decision-making skills to evaluate the appropriateness and medical necessity of requested services.
• Conduct accurate and timely pre-service (prospective) reviews for services requiring prior authorization.
• Complete accurate and timely post-service (retrospective) reviews for services that required prior authorization but were not obtained before being rendered.
• Document clear, concise case review summaries.
• Draft appropriate and accurate regulatory notices, including notices of action, non-coverage, or other communications to members and providers regarding utilization management decisions.
• Accurately apply and cite sources used in decision-making processes.
• Adhere to regulatory timelines for processing, reviewing, and completing case reviews.
• Apply utilization review principles, practices, and guidelines for members in skilled nursing and long-term care facilities.
• Conduct selective claims reviews.
• Perform chart audits to verify that ECM providers deliver essential ECM components, including outreach initiatives, comprehensive assessments, care plans, interventions, outreach documentation, and obtaining releases of information.
• Collaborate with the ECM Program Manager to develop audit tools, report templates, and other ECM-related forms or documents as needed.
• Attend ECM care coordination meetings as required.
• Assist in transitioning members from ECM to lower levels of care management in collaboration with ECM providers.
• Participate in meetings and committees related to ECM.
• Perform other duties as assigned.

You Will Be Successful If :

What You Will Bring :

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!