Health Plan Nurse Coordinator

Health Plan Nurse Coordinator

The Health Plan Nurse Coordinator is a Registered Nurse who supports one or more health services operational units, such as Utilization Management, Case Management, Enhanced Care Management, Disease Management, Pediatric-Whole Child Model, and Population Health programs. In this role, you perform utilization management activities including telephonic or onsite clinical review, as well as case or disease management, care coordination and transition, and population health activities for specific member populations. You collaborate closely with a multidisciplinary medical management team to promote high-quality, coordinated care and improved health outcomes for members. Bilingual Spanish skills may be required for positions that primarily involve direct interaction with members.

Responsibilities

• Perform utilization management activities, including telephonic and onsite clinical reviews, in alignment with health plan policies and procedures.
• Provide case management, disease management, care coordination, care transition, and population health services for assigned member populations.
• Comply with HIPAA, privacy, and confidentiality laws and regulations in all member and provider interactions and documentation.
• Adhere to health plan, medical management, and health services policies, procedures, and regulatory standards of governing agencies.
• Maintain up-to-date clinical knowledge related to disease processes, treatment modalities, and professional nursing standards of practice.
• Communicate effectively, verbally and in writing, with providers, members, vendors, and other health care professionals in a timely, respectful, and professional manner.
• Function as a collaborative member of the multidisciplinary medical management and health services 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 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.
• 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.
• Understand and apply quality improvement theory, strategies, and practical methods to achieve rapid-cycle improvement when assigned to quality improvement activities.
• Perform accurate HEDIS medical record abstraction when assigned to Quality Improvement functions.
• Participate actively in department meetings and contribute to a positive, flexible, and open approach toward operational changes.
• Support and work collaboratively with medical management and health services leadership in the implementation and management of UM, CM, DM, and Population Health activities.
• Contribute to the development, implementation, and evaluation of department initiatives aimed at improving members' quality of care and measuring outcomes.
• Stay current on health care benefits and limitations, regulatory requirements, community standards of care, and internal processes relevant to member services.
• Compose clear, professional, and grammatically correct correspondence to members and providers.
• Effectively manage multiple tasks, prioritize workload, and meet daily work timelines and deadlines, as well as deadlines for long-term projects.
• Demonstrate a professional demeanor and maintain excellent interpersonal communication skills in one-to-one and group settings.
• Embrace innovative care strategies and support continuous improvement in clinical and operational processes.

Essential Skills

• Active Registered Nurse (RN) license.
• Experience in utilization management and utilization review within a health plan or similar setting.
• Clinical knowledge of adult or pediatric health conditions and disease processes, depending on assignment.
• Ability to work effectively both independently and collaboratively in a cross-functional team environment.
• Strong multi-tasking, organizational, and time-management skills.
• Professional demeanor with excellent verbal, written, and interpersonal communication skills.
• Ability to communicate professionally by phone, in writing, and in person with members, families, physicians, providers, and other health care professionals.
• Ability to compose clear, professional, and grammatically correct correspondence.
• Ability to meet timelines and deadlines for daily responsibilities and long-term projects.
• Knowledge of and adherence to HIPAA, privacy, and confidentiality regulations.
• Ability to understand and apply quality improvement theory, strategies, and practical methods, when assigned.
• Ability to perform accurate HEDIS medical record abstraction, when assigned.
• Comfort working with diverse member populations in utilization management, case management, disease management, population health, and care coordination settings.

Additional Skills & Qualifications

• Experience working as a case manager in a health plan, hospital, or provider setting.
• Experience in medical management, health services, or population health programs.
• Experience supporting Enhanced Care Management, Disease Management, Pediatric-Whole Child Model, or similar sub-specialized programs.
• Familiarity with health care benefits, limitations, and regulatory requirements.
• Ability to identify and report quality-of-care concerns and participate in quality improvement initiatives.
• Bilingual Spanish skills for roles that primarily interact with members.
• Demonstrated flexibility, openness to operational changes, and a positive, collaborative attitude.
• Interest in and commitment to mission-driven work that improves community health and member outcomes.

Work Environment

This role is based in an office setting, working closely with a services team that includes Case Management, Pharmacy, Utilization Management, and Pediatric teams. You will be part of a small, collaborative care management team with other case managers and administrative staff who support each other and share knowledge. The broader organization is mission driven and places a strong emphasis on making a positive impact in the community while taking good care of employees. The work culture is supportive and team-oriented, with regular opportunities to collaborate across disciplines. The organization offers competitive compensation, a pension plan, professional development and wellness benefits, alternative transportation incentives, and comprehensive medical, dental, vision, and life insurance benefits. Employees also enjoy perks such as catered lunches on a weekly basis.

Job Type & Location

This is a Contract position based out of Santa Barbara, CA.

Pay and Benefits

The pay range for this position is $47.00 - $47.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available 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)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Aug 20, 2026.