Nurse Case Manager - UM & Care Coordination - Float

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time UM Care Transition Care Coordination Float Nurse. The Cross functional responsibilities within key units including Utilization Management, Inpatient Review, Care Coordination and Care Transitions. Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient AND outpatient preauthorization. Perform utilization review to ensure that HPSM members receive necessary medical care in a timely manner. Ensure that, initial and concurrent review for all outpatient admissions are completed within specified timeframes using evidence based criteria for medical appropriateness to support the admission level. Perform comprehensive individualized care planning and coordination with members across disciplines and settings.  Facilitate interdisciplinary collaboration to successfully transition HPSM members through various levels of care. 

The essential duties and responsibilities will include the following: 

• Review prior authorization requests for medical necessity using provided evidence based guidelines and HPSM benefit manuals, referring to the Medical Director those that require additional expertise
• Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate
• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
• Promote improved quality of care and/or life
• Promote cost effective medical outcomes
• Prevent hospitalization when possible and appropriate
• Promote decreased lengths of hospital stays when appropriate
• Provide continuity of care
• Assure appropriate levels of care are received by patients

• Utilize appropriate resources to guide review decisions and document decisions clearly and concisely.
• Work in collaboration and continuous partnership with “high-risk” members and their family/caregiver(s), primary care/specialty providers and staff, and community partners in a team approach to develop an individualized plan of care and linkage to relevant community resources.
• Provide accurate and sufficient documentation in the case management system that is reflective of nursing standards and HPSM internal policies and protocols.
• Coordinate an interdisciplinary approach to support timely access to appropriate care,
• facilitate continuity of care among providers and improve utilization of appropriate resources.
• Apply established principles of care transition and follow member through continuum of care as well as coordinate a warm hand-off to the appropriate provider for necessary involvement of continuation of care and services.
• Requirements

  Education and Experience: Valid California license as a Registered Nurse or Licensed Vocational Nurse (LVN). A Bachelor’s degree in nursing or a related health services field is a plus. Two (2) years of Utilization Management experience. Two (2) years of clinical nursing experience. Certification as Certified Case Manager (CCM) a plus.

  Knowledge of: Case management principles and practices. Managed Care Processes including use of Milliman Care Guidelines, Medi-Cal (Title 22), Medicare, or InterQual. Working knowledge of applicable and all relevant federal, state, and regulatory requirements. Medicare & Medi-Cal programs and benefits as well as community resources. The complexities of working with the elderly and disabled populations. Medicare and Medi-Cal programs and benefits as well as community resources. The complexities of working with the elderly and disabled populations. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint

  Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Adapt to changes in requirements/priorities for daily and specialized tasks

  Compensation and Benefits

  Starting Compensation Range: - Depending on Experience

  Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.