RN Chief Nursing Officer

Location: San Jose, CA
Date Posted: 06-29-2018
RN Chief Nursing Officer - TPA
San Jose, CA
Chief Nursing Officer Job Summary:
  • Responsible for all aspects of utilization management, care coordination, utilization compliance, authorizations referrals, and transitions of care and quality.
  • Work with Department Supervisors and leads management of authorization for Health Care Services.
  • Ensures that referrals are processed accurately and timely.
  • Ensures that referral guidelines are up to date and processed accurately and timely.
  • Ensures that approval, denial and other notifications are done in a timely and culturally competent manner, and in accordance with regulatory and plan requirements. 
  • Develop, coach and manage staff in order to provide high quality clinical care/service.
  • Provide clinical leadership and support to inpatient nurses and case managers to manage utilization, provide member-centric care, increase member engagement and ensure effective transitions of care. 
  • Develop and implement staff training, including onboarding, systems, and guideline usage in order to standardize processes and procedures. 
  • Draft policies and procedures to meet regulatory, plan and company requirements.
  • Determine appropriate staffing requirements and develop processes to interview, hire, and train and maintain the department staff.
  • Assesses professional development needs of staff and plans for training/continuing education of professional staff. 
  • With the Chief Medical Officer, work with Health Plans, IPAs and clients to meet delegation oversight as well as contracted UM standards. 
  • Participate in all Joint Operations Meetings and other key meetings as requested serve as Administrator for the Utilization Management Committee.
  • Manage quality and performance criteria, policies, procedures, and service standards for the utilization management department.
  • With the Chief Medical Officer and Director of Quality, analyze, interpret and develop actions plans to meet company goals and priorities. 
  • Ensure at plans integrate well across other departments in the continuum of care.
Chief Nursing Officer Background:
  • Valid, unrestricted state Registered Nurse (R.N.) license
  • Bachelor of Science in Nursing (B.S.N.) or related field required; Master’s degree a plus.
  • Certification in Case or Utilization Management, such as CCM, CPUM/CPUR/CPHM, is preferred.
  • Roughly 5 years of recent acute care clinical nursing experience.
  • Minimum of 3 years’ Utilization Management / Utilization Review / Care Coordination experience, including at least 1 year experience at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • At least 5 years of progressive management experience in a facility environment as an Associate Chief Nursing Officer or Nursing Director of multiple, complex nursing departments.
  • Knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
  • Experience in training / teaching staffs to meet operational requirements and goals.
  • Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
480.646.3275 (CALL – TEXT – FAX)
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