Job Description

Job Location Main Office - Santa Barbara, CA 93110 Position Type Full Time Education Level Bachelor's Degree Salary Range $84,877.00 - $123,072.00 Salary/year Job Category Medical Management

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.

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.
  
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• Follow Health Plan, Medical Management, and Health Services policies and procedures.
  
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• Maintain up-to-date clinical knowledge of disease processes.
  
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• Communicate effectively, professionally, and respectfully with providers, members, vendors, and healthcare teams both verbally and in writing.
  
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• Work as part of a multidisciplinary medical management team.
  
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• Identify and report quality of care concerns to management or the appropriate department.
  
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• Collaborate with management and team members in implementing Utilization Management (UM), Case Management (CM), Disease Management (DM), Population Health (PH), and care transition initiatives.
  
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• Participate in and support quality improvement activities related to job responsibilities.
  
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• Embrace operational changes with positivity and flexibility.
  
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• Comply with professional licensing requirements, regulatory standards, and governing agency timelines.
  
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• Attend and actively engage in departmental meetings.
  
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• Coordinate cost-effective, medically necessary services for members.
  
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• Facilitate care access and assist members in navigating the healthcare delivery system.
  
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• Provide education on health plan benefits, community resources, and self-management tools.
  
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• Conduct health screenings, assessments, and planning.
  
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• Develop, implement, and monitor individualized, member-centric care plans that meet regulatory requirements.
  
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• Perform telephonic assessments, surveys, and risk level determinations in a timely manner.
  
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• Review referral and service requests and apply clinical guidelines appropriately.
  
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• Perform prospective, concurrent, and retrospective reviews for services and document case summaries concisely.
  
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• Compose and issue regulatory-compliant notices of UM decisions.
  
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• Conduct on-site reviews of members in hospitals or care facilities.
  
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• Perform face-to-face assessments when required, such as using the CBAS assessment tool.
  
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• Work with members, families, caregivers, and healthcare providers to assess needs and coordinate services.
  
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• Partner with community-based organizations to arrange supportive services.
  
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• Coordinate seamless transitions between care levels (e.g., hospital to skilled nursing, skilled nursing to home).
  
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• Educate members on wellness and lifestyle practices to maintain or improve physical and mental health.
  
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• Document assessments, care plans, and case summaries clearly and accurately.
  
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• Ensure adherence to regulatory timelines for risk assessments, surveys, and care plans.
  
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• Support innovation in care strategies and value-based program development.
  
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• Act as a liaison for UM processes and operational standards.
  
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• Address transitional needs for members aging into adulthood as required.
  
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• Perform other duties as assigned.
  
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Qualifications

Knowledge / Skills / Abilities

Required

• Maintain a professional demeanor in all interactions.
  
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• Exhibit strong multitasking, organizational, and time-management abilities.
  
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• Demonstrate clinical knowledge of adult or pediatric health conditions and disease processes, depending on assignment.
  
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• Work effectively both independently and collaboratively within cross-functional teams.
  
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• Communicate professionally by phone, in writing, and in-person with members, families, physicians, providers, and other healthcare professionals.
  
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• Display excellent interpersonal communication skills.
  
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• Compose clear, professional, and grammatically correct correspondence for members and providers.
  
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• Meet deadlines for daily responsibilities and long-term projects.
  
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• Demonstrate proficiency in organizing and managing work assignments.
  
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• Understand and apply quality improvement theories, strategies, and methods to achieve rapid-cycle improvement (for Quality Improvement assignments).
  
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• Accurately apply and interpret clinical guidelines.
  
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• Perform accurate HEDIS medical record abstraction as assigned.
  
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• Utilize IT UM databases and electronic clinical guidelines effectively.
  
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• Compose accurate and grammatically correct Notices of Action or denial notices, using appropriate templates and citations with minimal errors.
  
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• Maintain a thorough understanding of Medi-Cal coverage and limitations.
  
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• For Pediatric Department assignments, demonstrate expertise in CCS eligibility and clinical guidelines.
  
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• Develop, implement, and measure outcomes of Individualized Care Plans.
  
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• Ensure ICPs are timely, concise, member-centric, and goal-focused with minimal timeline adjustments.
  
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• Accurately categorize cases by program, type, acuity, and intensity.
  
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• Act as a mentor for new Health Plan Nurse Coordinators in Utilization Management and Case Management.

Preferred

• Knowledge of Medi-Cal and/or Medicare benefits, managed care regulations, including contract limitations, delivery, reimbursement systems, and the role of medical management activities.
  
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• Understand basic utilization review principles and practices.
  
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• Familiarity with case and disease management concepts as outlined by the Case Management Society of America.
  
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• Basic knowledge of quality improvement and population health principles.
  
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Education and Experience

Required

• Possess a current, active, and unrestricted California Registered Nurse (RN) or Nurse Practitioner (NP) license.
  
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• A minimum of two (2) years of experience in a nursing role.
  
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Preferred

• 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.
  
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• 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.