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

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

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

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.