Under general direction, is responsible for providing Care/Case Management and Disease Management duties within the Ventura County Health Care Plan (VCHCP). Established during the 1993-1994 fiscal year, the VCHCP was developed as a practical and cost-effective option for providing health care services to County employees and their covered dependents.
The Senior Registered Nurse-Ambulatory Care series is distinguished from other nursing classifications in that they will provide Care/Case management, Disease Management, Wellness and Prevention, Utilization Management and tasks related to Healthcare Effectiveness Data and Information Set (HEDIS) as well as writing reports and analyses in line with the National Committee for Quality Assurance (NCQA) regulatory requirements and programs affiliated with the Ventura County Health Care Plan. It requires that incumbents demonstrate advanced competency skills and knowledge specific to telephonically case managing complex cases, disease managing certain populations, performing utilization reviews, supervising HEDIS documentation, and writing required analyses to meet or align with NCQA standards in a managed care health plan. The incumbents are expected to work at the full scope of their licensure, with a decreasing amount of supervision commensurate with their experience.
PAYROLL TITLE: Senior Registered Nurse – Ambulatory Care
AGENCY/DEPARTMENT: Health Care Agency - Ventura County Health Care Plan
Senior Registered Nurse-Ambulatory Care is represented by the California Nurses Association (CNA) and is eligible for overtime compensation. Salary placement will be determined according to the current California Nurses' Association (CNA) memorandum of agreement.
The eligible list established from this recruitment may be used to fill current and future Regular (including Temporary and Fixed-term), Intermittent, and Extra Help vacancies for this position only. There is currently one (1) Full-Time Regular vacancy in Utilization Management (UM) with the Ventura County Health Care Plan.
TENTATIVE SCHEDULE
OPENING DATE: 8/6/24
FIRST REVIEW DATE: 8/20/24
CLOSING DATE: Continuous
Duties may include but are not limited to the following:
- Performs utilization review with pre-certification, concurrent, retrospective, out of network and medical appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policies, member eligibility benefits, contracts and industry standards/guidelines;
- Performs telephonic care/case management within the scope of licensure for Plan members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans to optimize member health care across the care continuum, ensuring member access to services appropriate to their health needs; and facilitates authorizations/referrals as appropriate within benefit structure or through extra contractual arrangements;
- Coordinates internal and external resources to meet identified needs and address objectives and goals identified during assessment. Interfaces with Medical Directors, Physician Reviewers, treatment team, member, and families on the development of care/case management treatment plans.
- Assists in problem solving with providers and/or patients on claims or service issues;
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required;
- Facilitates compliance with regulatory requirements and standards by knowing, understanding, correctly interpreting, and accurately applying regulatory requirements of the Department of Managed Health Care (DMHC) and standards;
- Administers and oversees wellness and prevention programs, ensuring that members are informed, engaged, and benefit from initiatives aimed at promoting health, preventing diseases, and maintaining well-being;
- Assumes responsibilities related to HEDIS, including data collection, reporting, and ensuring compliance with HEDIS measures and standards, as well as collaborating with members and providers to close care gaps;
- Assumes responsibility for writing required analyses that align with the NCQA requirements within the health plan's framework.
- Performs disease management for certain health plan population; and
- Performs other related duties as required.
These are entrance requirements to the examination process and assure neither continuance in the process nor placement on an eligible list.
EDUCATION, TRAINING, and EXPERIENCE:
Requires three (3) years of full-time professional registered nursing experience, including two (2) years of full-time experience in Case Management, Disease Management, Quality Assurance, HEDIS and/or Utilization Review.
NECESSARY SPECIAL REQUIREMENTS
- Must possess and maintain a current, valid license as a Registered Nurse issued by the State of California.
- Must have a current, valid Basic Life Support (BLS/CPR) certification by first day of employment.
- Depending upon the area of assignment, additional specialty experience and/or certification(s) may be required.
- Certified in Case Management, CCM.
- Experience with Utilization Management and/or Quality Assurance in a Managed Health Care Plan;
- Experience working as a case manager in a health plan case managing complex cases;
- Demonstrated experience in the administration of wellness and prevention programs;
- Experience in meeting or exceeding NCQA requirements, including project management responsibilities;
- Experience related to HEDIS, including data collection, reporting, and ensuring compliance with HEDIS measures and standards.
- Experience utilizing the care planning process as part of the case management process;
- Experience with disease management in a health plan; managing population members with diseases such as diabetes, asthma, etc.
Considerable to thorough knowledge of:
- Principles, practices, techniques and methods used in Utilization review/management, case management, wellness and prevention or disease management;
- Regulatory requirements of the Department of Managed Health Care (DMHC) and National Committee for Quality Assurance (NCQA) regulatory requirements.
- Problem solving/conflict resolution;
- Organization to manage all aspects of a client’s case.
- Facilitate member care transition through the healthcare continuum and refers treatment plan/plan of care to clinical reviewers as required;
- Maintain confidentiality of patient/client information;
- Effectively maintain a positive working relationship with the medical staff, public, patients, and family members;
- Communicate effectively, both orally and in writing.
To apply on-line, please refer to our web site at . If you prefer to fill out a paper application form, please call (805) 654-5129 for application materials. Our address is: County of Ventura, Human Resources Division, 800 S. Victoria Ave., Loc. # 1970, Ventura, CA 93009.
NOTE: It is essential that you complete all sections of your application and supplemental questionnaire thoroughly and accurately to demonstrate your qualifications. A resume and/or other related documents may be attached to supplement the information in your application and supplemental questionnaire; however, it/they may not be submitted in lieu of the application.
LATERAL TRANSFER OPTION: If presently permanently employed in another "merit" or "civil service" public agency/entity in the same or substantively similar position as is advertised, and if appointed to that position by successful performance in a "merit" or "civil service" style examination, then appointment by "Lateral Transfer" may be possible. If interested, please click here for additional information.
SUPPLEMENTAL QUESTIONNAIRE – qualifying: All applicants are required to complete and submit the questionnaire for this examination at the time of filing. The supplemental questionnaire may be used throughout the examination process to assist in determining each applicant's qualifications and acceptability for the position. Failure to complete and submit the questionnaire will result in the application being removed from consideration.
APPLICATION EVALUATION – Pass/Fail: An application evaluation will be conducted. A score will be assigned to each application based on established criteria. Such score will be considered as the final score for placement on the eligible list.
Applicants successfully completing the examination process may be placed on an eligible list for a period of one (1) year.
BACKGROUND INVESTIGATION: A thorough pre-employment, post offer background investigation which may include inquiry into past employment, education, criminal background information, and driving record may be required for this position.
EQUAL EMPLOYMENT OPPORTUNITY:
The County of Ventura is an equal opportunity employer to all, regardless of age, ancestry, color, disability (mental and physical), exercising the right to family care and medical leave, gender, gender expression, gender identity, genetic information, marital status, medical condition, military or veteran status, national origin, political affiliation, race, religious creed, sex (includes pregnancy, childbirth, breastfeeding, and related medical conditions), and sexual orientation.
For further information about this recruitment, please contact Brett Ramirez by e-mail at or by telephone at (805) 654-2277.
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