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Pediatric CM Nurse Coordinator-Bilingual, Santa Barbara, CA


CenCal Health

Nurse

Santa Barbara, CA

September 20, 2018


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Pediatric CM Nurse Coordinator-Bilingual

Clinical or Medical

Posted: November 9, 2017
Full-Time
Santa Barbara, CA, United States

Job Details

Description

The CenCal Health Pediatric CM Nurse Coordinator is a blended role that incorporates the responsibilities of case management and utilization management activities. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates services required to meet the member’s health care needs and to the extent possible, address their social needs. CM activities include advocacy, coordination, communication, resource management, and the promotion of quality and cost-effective interventions and outcomes/goals. UM activities include reviewing prospective and retrospective requests for authorization and referrals, performing concurrent inpatient review, coordinating inpatient transfers and care transitions activities. The Pediatric CM Nurse Coordinator assist specific members under the age of 21, who qualify for the Pediatric Whole-Child Program with care coordination, which include processing medically necessary service requests, facilitating care transitions, and communicating with members and providers to assure the medical needs of the member are met. The Pedi CM Nurse Coordinator will assist members and their families by optimizing their wellness level and improve or maintain their functional capabilities by empowering them with education and self-managing tools, and assisting with care coordination or care transition.

This position is responsible for coordinating and managing specific CenCal Health members for defined periods of time and/or post discharge transition from an inpatient setting (e.g. acute care hospital, skilled or long-term care facility) to ensure that member’s outpatient care is being coordinated and that all medically necessary services are being provided in a timely manner. In addition, this position requires the management of complex care members over longer periods as deemed appropriate, and potentially preventable admissions.

Responsibilities include but are not limited to:

  • Coordinate the provision of quality and cost-effective health care services
  • Coordinate care and services for members and effectively and efficiently implement and complete the care management process. This process involves health screening, assessment, care planning, coordination of care, and monitoring of member’s progress and compliance
  • Collaboratively develop realistic individualized care plan with member and their family
  • Perform concurrent review of hospitalized member
  • Assist with discharge planning and care transitions from one care setting to another
  • Process service requests and specialty referrals in a timely manner
  • Collaborate with the member, the member’s family or caretaker, primary care provider, and other health care providers
  • Coordinate timely care transition from one level of care to another, such acute to SNF or SNF to home or other living arrangement as the member’s care needs change
  • Effectively communicate and educate members about the health care delivery system and health plan benefits and limitations
  • Identify care needs of the member, identify interventions, develop plan of care, implement necessary services, and establish timelines for case management services
  • Effectively communicate verbally and in writing with primary care providers and other health care providers involved in the member’s care
  • Adhere to Health Plan and department specific policies and procedures
  • Collaborate with contracted agencies and community based organizations to provide supportive services when needed (VNA- home nursing, PT, Meals on Wheels etc.)
  • Support and collaborate with the management and health services team members in the implementation and management of CM activities
  • Actively participate in the development, implementation and evaluation of department initiatives with the intent to assess and evaluate any measurable improvements to member’s quality of care
  • Other duties as assigned

Qualifications

Skills

Preferred

Outlook Intermediate
Microsoft Office Intermediate

Experience

Required

Bi-lingual-English and Spanish
Current, Active RN License
2 years: Registered Nurse in outpatient, inpatient or office setting

Preferred

Prior UM/CM experience in a managed care setting
Certification in case management, utilization review or healthcare management
1 year: Clinical Experience working with pediatric population

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