Health Plan Nurse Coordinator

This is a remote position with quarterly in-office meetings, supporting health services operational units such as Utilization Management, Case Management, Enhanced Care Management, Disease Management, Pediatric–Whole Child Model, and Population Health programs. Bilingual proficiency in Spanish may be required for roles involving direct member interaction.

About the role

The Health Plan Nurse Coordinator is a Registered Nurse who performs utilization management activities, including telephonic or onsite clinical review, case or disease management, care coordination, transitions of care, or population health activities for specific member populations. The role collaborates closely with a multidisciplinary medical management team to promote high-quality, cost-effective care and support members in navigating complex health care needs.

Responsibilities

• Comply with HIPAA, privacy, and confidentiality laws and regulations.
• Adhere to health plan, medical management, and health services policies and procedures.
• Maintain current clinical knowledge related to disease processes and evidence-based treatment modalities relevant to assigned populations.
• Communicate clearly and professionally, both verbally and in writing, with members, families, providers, vendors, and other health care professionals in a timely and respectful manner.
• Function as a collaborative member of the medical management and health services multidisciplinary team.
• Identify and report quality of care concerns to management and, as directed, to the appropriate internal department for follow-up.
• Support and collaborate with medical management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Population Health, Care Coordination, and Care Transition activities.
• Perform utilization management activities, including telephonic or onsite clinical reviews, as required by the assigned unit.
• Conduct case management or disease management activities, including assessment, care planning, coordination, and monitoring for specific member populations.
• Participate in care coordination and care transition activities to support safe and effective movement of members across care settings.
• Actively participate in the implementation, assessment, and evaluation of quality improvement activities related to assigned job duties.
• Adhere to mandated reporting requirements consistent with professional licensing standards.
• Comply with regulatory standards established by governing agencies and ensure that utilization and case management practices align with those standards.
• Demonstrate flexibility and openness to operational changes, adapting workflows and priorities as needed.
• Attend and actively participate in department meetings, contributing to discussions, planning, and problem-solving.
• Support and work collaboratively with the medical management and health services management team in the implementation and ongoing management of UM, CM, DM, and population health initiatives.
• Participate in the development, implementation, and evaluation of department initiatives designed to improve members’ quality of care and measure outcomes.
• Stay informed about health care benefits and limitations, regulatory requirements, community standards of care, and professional nursing standards of practice.
• When assigned to quality improvement functions, understand and apply quality improvement theory, strategies, and practical methods to achieve rapid-cycle improvement.
• When assigned to quality improvement functions, perform accurate HEDIS medical record abstraction in accordance with established guidelines.
• Manage daily workload and long-term projects to meet timelines and deadlines, ensuring accurate documentation and follow-through on all assigned tasks.

Requirements

• Active California Registered Nurse (RN) license.
• Experience in utilization management for both inpatient and outpatient care settings.
• Experience working with Medi-Cal, Medicare, and Medicaid programs.
• Professional demeanor and the ability to represent the health plan in a positive and respectful manner.
• Strong multitasking, organizational, and time-management skills to handle multiple cases and priorities effectively.
• Clinical knowledge of adult or pediatric health conditions and disease processes, depending on unit assignment.
• Ability to work effectively both independently and collaboratively in a cross-functional team environment.
• Ability to communicate professionally by phone with members, families, physicians, providers, and other health care professionals.
• Strong written communication skills, including the ability to compose clear, professional, and grammatically correct correspondence to members and providers.
• Ability to meet timelines and deadlines for daily work responsibilities and longer-term projects.
• Understanding of quality improvement concepts and methods, with the ability to apply these principles when assigned to quality improvement activities.
• Accuracy and attention to detail when performing HEDIS medical record abstraction, when assigned.

Qualifications

• Bilingual proficiency in Spanish for roles that primarily interact with members.
• Experience in case management, care coordination, disease management, or population health within a health plan or similar environment.
• Background working with hospitals, providers, and health plans in a coordinated care setting.
• Familiarity with utilization review processes and standards.
• Strong interpersonal skills with the ability to build rapport and collaborate with multidisciplinary teams.
• Comfort working in a remote environment while maintaining productivity and engagement with team members.
• Interest in professional development and ongoing learning related to nursing practice, health plan operations, and quality improvement.

Benefits

• Comprehensive medical, dental, and vision insurance.
• Critical Illness, Accident, and Hospital coverage.
• 401(k) Retirement Plan with pre-tax and Roth post-tax contributions.
• Life Insurance (Voluntary Life & AD&D for the employee and dependents).
• Short and long-term disability.
• Health Spending Account (HSA).
• Transportation benefits.
• Employee Assistance Program.
• Time Off/Leave (PTO, Vacation, or Sick Leave).
• Pension plan.
• Professional development and wellness benefits.
• Alternative transportation incentives.

Pay

$47.00 - $47.00/hr.

Schedule

This is a contract position based out of Remote, OR.