Health Plan Nurse Coordinator - Community Supports

Description :

The Health Plan Nurse Coordinator Community Supports - (HPNC CS) is a Registered Nurse who is assigned to the Community Support unit. The HPNC performs utilization management activities, which may include telephonic or onsite clinical reviews, care coordination, or transition of care for support for Members eligible for Community Supports (CS). The HPNC-CS serves as a supportive resource for CS providers regarding authorization processing, CS services, and plan benefits, aiming to support Members in CS. Bilingual in Spanish may be required for positions that primarily interacts with members.

What You Will Do :

• Comply with HIPAA, Privacy, and Confidentiality laws and regulations
• Adhere to Health Plan, Medical Management and Health Services policies and procedures
• Comply with regulatory standards of governing agency
• Adhere to mandated reporting requirements as per professional licensing requirements
• Function as a collaborative member of Medical Management / Health Services multi-disciplinary team
• Attend and actively participate in department meetings
• Collaborate with CS Program Manager to develop audit tools, report templates, or other CS forms / documents as requested.
• Attend CS care coordination meetings, as needed.
• Participate in meetings / committees related to CS
• Identify and report quality of care concerns to management and appropriate departments for follow up
• Perform accurate and timely prospective (pre-service) and retrospective (post- Service) reviews for services requiring prior authorization
• Conduct chart audits to ensure CS providers are providing the core components : outreach initiatives, comprehensive assessments, care plans, interventions, outreach documentation, and obtaining releases of information
• Apply utilization review principles, practices, and guidelines for members in skilled nursing and long-term care facilities
• Perform selective claims review
• Document clear and concise case review summaries

Compose appropriate and accurate draft notice of action, non-coverage, or other regulatory required notices to members and providers regarding UM

decisions

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!