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

About the position 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.

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.

Requirements

• 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.
• 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.

Nice-to-haves

• 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.
• 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.

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