Senior Medical Management Nurse - VCHCP

Overview

Come be part of our Ventura County workforce in the Ventura County Health Care Plan's (VCHCP) Quality Management Department. VCHCP is a County sponsored Health Maintenance Organization (HMO) offering a range of benefits and low out-of-pocket expenses. VCHCP is dedicated to excellence in service and care.

As a member of the Quality Management team in VCHCP, you will help ensure patient care meets safety, effectiveness, and satisfaction standards. The goal is to foster a culture of excellence and accountability where continuous feedback and improvement drive safer, more efficient, patient-centered care.

Under general direction, the Senior Medical Management Nurse is responsible for utilization review, case management, and quality improvement functions to ensure members receive appropriate, cost-effective, and high-quality care. Duties include pre-certification, concurrent, and retrospective reviews; developing and coordinating care plans for members with complex or chronic conditions; and facilitating smooth care transitions across the healthcare continuum. The incumbent collaborates with medical directors, providers, and members to resolve service issues, ensure regulatory compliance (DMHC, NCQA, HEDIS), and support wellness, prevention, and disease management programs.

This role supports optimal health outcomes while adhering to health plan policies and industry standards.

Join us and apply your skills and ideas to improving the lives of our members and the quality of care they receive.

The County of Ventura offers an attractive compensation and benefits package. In addition to the base salary range, employees in this position may be eligible for the following benefits, subject to eligibility requirements:

• Educational Incentive: An educational incentive of 2.5% for an associate’s degree, 3.5% for a bachelor’s degree, or 5% for a graduate degree.
• Bilingual Incentive: Proficiency-based hourly incentives by exam:
  Level I $0.69, Level II $1.00, Level III $1.32.
• Certification Pay: $0.813 per hour for each qualified certification (up to five); one certification may be paid at $2.00 per hour if it is a National Certification. See MOA Exhibit 9.
• Continuous County Service Incentive Pay: 1% for 7 years, 1.25% for 12 years, 1.5% for 17 years.
• Flexible Credit Allowance: Biweekly contribution towards medical, dental, and/or vision insurance from authorized plans.
• Deferred Compensation: Eligible to participate in the County’s 401(k) Shared Savings Plan and/or Section 457 Plan with up to a 2% match.
• Pension Plan: Participation in the County’s defined benefit pension plan; reciprocity with other public retirement systems (e.g., CalPERS) where eligible.
• To learn more about the benefits: _.pdf (ventura.org).

Payroll

Title:

Senior Registered Nurse – Ambulatory Care

Duties may include but are not limited to the following:

• Perform utilization review with pre-certification, concurrent, retrospective, out-of-network, and medical appropriateness reviews to ensure compliance with criteria, policies, member benefits, contracts, and guidelines.
• Provide telephonic care/case management for plan members with complex and chronic needs; assess, develop, implement, coordinate, monitor, and evaluate care plans; authorize referrals as appropriate within benefit structures.
• Coordinate internal and external resources; interface with Medical Directors, physicians, treatment teams, patients, and families to develop care/case management plans.
• Assist in problem solving with providers or patients on claims or service issues.
• Facilitate member care transitions through the continuum and refer plans to clinical reviewers as required.
• Ensure regulatory compliance with DMHC and NCQA requirements.
• Administer and oversee wellness and prevention programs to engage members and promote health.
• Manage data collection and reporting for HEDIS measures and collaborate to close care gaps;
• Contribute to NCQA-required analyses within the health plan’s framework; perform disease management for select populations; perform other related duties as required.

Education, Training, and

Experience:

Requires three (3) years of…