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Health Plan Registered Nurse, Santa Barbara, CA

CenCal Health


Santa Barbara, CA

July 30, 2019

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Health Plan Registered Nurse

Clinical or Medical HEALT01129
Posted: April 8, 2019
Santa Barbara, CA, USA

Job Details


When assigned to the Utilization Management Department, responsibilities include but are not limited to:

  • Timely review of request for services and based on established clinical guidelines and/or benefits limitations
  • Determine appropriateness of requested services Conduct face-to-face interviews with the member and/or authorized representative, family, caregiver, etc. to complete necessary assessment tools
  • Accurate interpretation of established clinical guidelines
  • Perform timely prospective review for services requiring prior authorization
  • Perform timely concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care setting
  • Perform timely retrospective review for services that required prior authorization but was not obtained by the provider
  • Support and collaborate with the UM and CM Clinical Managers in the implementation and management of UM/CM activities
  • Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member’s quality of care
  • Perform selective claims review, and occasional onsite review
  • Adhere to regulatory timeframes for completion of reviews
  • Keep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice
  • Apply utilization review principles, practices, and guidelines as appropriate to members in skilled nursing facilities
  • Other duties as assigned

When assigned to the Case Management (Adult) Department, 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, planning, coordination of care, and monitoring of member’s progress and compliance
  • Collaborate with the member, the member’s family or caretaker, primary care provider, and other health care providers
  • Develop, update and monitor member-centered, individualized care plans in adherence to regulatory standards
  • Conduct telephonic assessments and questionnaires and determine risk level from results in adherence to regulatory guidelines
  • 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
  • Other duties as assigned

When assigned to the Pediatric Care Coordination Department, responsibilities include but are not limited to:

The Health Plan Registered Nurse in the Pediatric Care Coordination Department has a blended role that incorporates the responsibilities noted above for utilization management and case management departments. The Health Plan Registered Nurse in this Department assists specific members under the age of 21, who qualify for the Pediatric Whole-Child Program with care coordination. This includes but is not limited to timely review and processing of medically necessary service requests; facilitating care transitions; conducting timely telephonic questionnaires and assessments; developing timely individualized care plans; 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.

In addition to the above department-specific responsibilities, the Health Plan Registered Nurse responsibilities include but are not limited to the following:

  • Identify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow up
  • Work in collaboration with the multidisciplinary teams to assess the needs of the member.
  • Comply with HIPAA, Privacy, and Confidentiality laws and regulations
  • Continually update clinical knowledge base related to disease processes
  • Continually update knowledge base related to data entry and computer technology used by CenCal Health
  • Effectively communicate verbally and in writing with primary care providers, vendors, and other health care providers involved in the member’s care
  • Adhere to Health Plan and Health Services specific policies and procedures
  • Collaborate with contracted agencies and community based organizations to provide supportive services when needed (Home Health agencies, Outpatient Therapy Units, Meals on Wheels, Recuperative Care, Shelters, etc.)
  • Support and collaborate with the management and health services team members in the implementation and management of Utilization Management, Case Management, Care Coordination, and Care Transition activities
  • As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job duties
  • Adhere to mandated reporting requirements appropriate to professional licensing requirements
  • Other duties as assigned




  • Microsoft Office Intermediate



  • Dedicated: Devoted to a task or purpose with loyalty or integrity
  • Thought Provoking: Capable of making others think deeply on a subject
  • Team Player: Works well as a member of a group
  • Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well



  • Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization



  • Able to understand Adult or pediatric health conditions and disease processes


  • Understand basic case management concepts and principles as described in the Case Management Society of America
  • Knowledge of Medi-Cal and/or Medicare health care benefits, managed care regulations and role of medical management activities
  • Prior UM/CM experience in a managed care setting

Licenses & Certifications


  • Registered Nurse


  • Case Management Cert

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