Health Plan Nurse Coor. UM Adult

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

​​​​​​​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 – Adult Utilization Management (HPNC – Adult UM) is a Registered Nurse assigned to the Utilization Management unit. This position reports to the Utilization Management Supervisor or their designee for the assigned unit. The following are the core responsibilities:

• Perform utilization management activities – This is the core overarching responsibility and encompasses all tasks related to managing the appropriate use of healthcare services.

• Conduct telephonic or onsite clinical reviews – This specifies the method of carrying out utilization management, representing a significant function under the broader UM umbrella.

• Coordinate care and manage transitions of care – This refers to ensuring members receive appropriate, continuous, and coordinated care across different healthcare settings.

• Communicate effectively with members, potentially in Spanish – While not always required, this responsibility highlights the importance of member interaction and language proficiency for certain roles.

Duties and Responsibilities

1. Perform utilization management activities

• Duties related to UM reviews, application of guidelines, and decision-making processes:

• Review requests for referrals and services in a timely manner.

• Apply and interpret established clinical guidelines and benefits limitations.

• Use accurate decision-making skills to support the appropriateness and medical necessity of requested services.

• Conduct accurate and timely prospective (pre-service) reviews for services requiring prior authorization.

• Perform timely concurrent reviews for inpatient care in acute care, subacute, skilled nursing, and long-term care settings.

• Carry out accurate and timely retrospective (post-service) reviews for services requiring prior authorization but not obtained by the provider before service delivery.

• Conduct selective claims reviews.

• Apply utilization review principles, practices, and guidelines as appropriate for members in skilled nursing and long-term care facilities.

2. Conduct telephonic or onsite clinical reviews

• Duties related to direct clinical contact and assessments:

• As assigned, conduct face-to-face assessments of members and/or their authorized representatives, family, caregivers, etc., to complete necessary assessments (e.g., CBAS assessment tool).

• As assigned, perform onsite reviews of members in acute hospitals, skilled nursing facilities, and other inpatient settings.

• Conduct accurate and timely reviews (prospective, concurrent, retrospective) as part of clinical decision-making.

3. Coordinate care and manage transitions of care

• Duties related to cross-setting care continuity and interdisciplinary work:

• Collaborate with management, medical management, and health services teams in the implementation and management of Utilization Management, Care Coordination, and Care Transition activiti