County of Contra Costa
Health Plan Nurse Program Director
County of Contra Costa, Martinez, California, United States, 94553
Overview
Contra Costa Health is offering an excellent opportunity for two Health Plan Nurse Program Directors within the Contra Costa Health Plan (CCHP) division. One position will be assigned to Clinical Operations and the other in Utilization Management. Contra Costa Health Plan (CCHP) has been serving county residents for over 50 years and was the first federally qualified, state-licensed, county-sponsored Health Maintenance Organization (HMO) in the United States. Established in 1973, CCHP is the largest managed care health plan in Contra Costa County, serving over 250,000 residents. CCHP is committed to equitable, accessible, and coordinated care for diverse members. These leadership positions are critical to advancing CCHP’s mission of providing affordable, high-quality healthcare to all.
We are looking for someone who is:
Experienced in Managed Care:
Brings proven experience in medical management, clinical operations, and utilization management within a health plan or managed care setting
Knowledgeable in Medicaid and Medicare:
Demonstrates strong understanding of Medi-Cal and Medicare Programs, including compliance, operations, and delivery systems
A Critical Thinker:
Able to analyze complex clinical and operational issues, evaluate data, and make sound, evidence-based decisions
Proactive:
Anticipates needs, takes initiative, and drives solutions forward
A Team Player : Works collaboratively across departments and with external partners to achieve shared goals
A Leader:
Skilled at directing teams and managing complex operations
Action-Oriented:
Able to prioritize and deliver results in a fast-paced environment
A Strong Communicator:
Comfortable interacting with staff, providers, members, and external partners
Equity-Minded:
Committed to supporting Contra Costa’s culturally and linguistically diverse community
Compliance-Focused:
Knowledgeable in state, federal, and managed care requirements
Responsibilities When Assigned to Clinical Operations
Directs CCHP’s day-to-day clinical operations within & between all Clinical Operations Departments, including, but not limited to: Utilization Management, Case Management, Clinical Quality Auditing, and Advice Nurse Unit
Coordinates inter-departmental activity to synergize operational impact
Develops and implements clinical policies and workflows that improve access, efficiency, and member experience
Coordinates with providers, community partners, and county divisions to meet member needs
Leads efforts to improve operational efficiency in clinical workflows, ensuring members receive the right care, at the right time, in the right setting
Monitors and evaluates program performance to meet regulatory requirements and achieve positive health outcomes
Supports staff development and mentors a team of nurses, social workers, and health educators
Serves as a key liaison between CCHP clinical teams, community-based organizations, and other County departments
When Assigned to Utilization Management
Oversees utilization management (UM) functions including prior authorization review, retrospective review, concurrent review, and discharge planning
Supervises UM nurses and staff, ensuring adherence to medical necessity standards and regulatory requirements
Collaborates with Medical Directors and Chief Medical Officer
Monitors UM operations for timeliness, compliance, and alignment with evidence-based practice guidelines
Ensures UM processes comply with all Medi-Cal (DHCS), Medicare (CMS), DMHC, and NCQA requirements
Collaborates with hospitals, facilities, and providers to support timely discharges, reduce readmissions, and improve care coordination
Develops and refines UM policies, workflows, and decision-making standards to align with evidence-based practices and maintain regulatory compliance
Prepares and presents UM reports to internal leadership, external regulators, and governing committees
Additional Responsibilities
Directing and supervising clinical and administrative staff in either clinical operations or utilization management
Providing clinical oversight, coaching, and mentoring to team members
Developing and implementing operational programs, policies, and workflows
Ensuring compliance with DHCS, DMHC, CMS, and other regulatory requirements
Coordinating with providers and partners to improve care access and outcomes
Preparing reports and documentation for leadership, regulators, and accrediting bodies
Why you might love this job
You will play a vital role in ensuring Contra Costa residents receive timely, high-quality care
You will lead teams that make a real difference in members’ health and well-being
You will work in a mission-driven, equity-focused organization with a supportive leadership team
We offer generous benefits and a competitive retirement package
Challenges you might face
Navigating complex regulatory requirements while balancing operational needs
Managing high-volume workloads and competing priorities
Leading staff through change in a dynamic healthcare environment
Competencies Required
Critical Thinking & Problem Solving:
Analytically and logically evaluating information, identifying solutions, and making sound decisions
Legal & Regulatory Navigation : Interpreting and applying compliance requirements
Leadership & Accountability : Guiding staff to achieve shared goals
Strategic Thinking : Balancing short-term operational demands with long-term priorities
Systems Thinking : Connecting clinical operations or utilization management with overall plan strategy
To read the complete job description, please refer to the recruitment materials. The eligible list established from this recruitment may be used to fill future openings for up to 6 months.
License Required:
Candidates must possess and maintain throughout the duration of employment: a current, valid, and unrestricted Registered Nurse license issued by the California Board of Registered Nursing.
Applicants are required to attach a copy of their license and transcripts to their application.
Education:
Possession of a Master’s Degree in nursing, hospital or health care administration, or a closely related field, from an accredited college or university.
Experience : Five (5) years of full-time experience, or its equivalent, as a Registered Nurse, Utilization Review Nurse, Discharge Planner, Case Management Nurse, or a Telephone Triage Registered Nurse in a healthcare or managed care setting (e.g. Preferred Provider Organization, Managed Care Organization, or Health Maintenance Organization), at least one (1) year must have been at a supervisory level.
Substitution : Possession of a Bachelor’s Degree in one of the fields noted above plus two (2) additional years of supervisory experience of the type noted above may be substituted for the Master’s Degree. There is
no
substitution for the one (1) year of supervisory experience.
Possession of a Certified Case Manager (CCM) certification issued by the Commission for Case Manager Certification may be substituted for one (1) year of the required experience.
Application and selection
Application Filing and Evaluation:
Applicants will be required to complete a supplemental questionnaire at the time of application. Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.
Training & Experience Evaluation:
Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated. The responses to the supplemental questions, at the time of filing, will be evaluated to determine each candidate's relevant education, training, and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)
For recruitment questions, please contact Health Services Personnel, Recruitment Team at Exams@cchealth.org. For any technical issues, please contact the Government Jobs’ applicant support team for assistance at +1 855-524-5627.
The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.
Equal Employment Opportunity It is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.
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Contra Costa Health is offering an excellent opportunity for two Health Plan Nurse Program Directors within the Contra Costa Health Plan (CCHP) division. One position will be assigned to Clinical Operations and the other in Utilization Management. Contra Costa Health Plan (CCHP) has been serving county residents for over 50 years and was the first federally qualified, state-licensed, county-sponsored Health Maintenance Organization (HMO) in the United States. Established in 1973, CCHP is the largest managed care health plan in Contra Costa County, serving over 250,000 residents. CCHP is committed to equitable, accessible, and coordinated care for diverse members. These leadership positions are critical to advancing CCHP’s mission of providing affordable, high-quality healthcare to all.
We are looking for someone who is:
Experienced in Managed Care:
Brings proven experience in medical management, clinical operations, and utilization management within a health plan or managed care setting
Knowledgeable in Medicaid and Medicare:
Demonstrates strong understanding of Medi-Cal and Medicare Programs, including compliance, operations, and delivery systems
A Critical Thinker:
Able to analyze complex clinical and operational issues, evaluate data, and make sound, evidence-based decisions
Proactive:
Anticipates needs, takes initiative, and drives solutions forward
A Team Player : Works collaboratively across departments and with external partners to achieve shared goals
A Leader:
Skilled at directing teams and managing complex operations
Action-Oriented:
Able to prioritize and deliver results in a fast-paced environment
A Strong Communicator:
Comfortable interacting with staff, providers, members, and external partners
Equity-Minded:
Committed to supporting Contra Costa’s culturally and linguistically diverse community
Compliance-Focused:
Knowledgeable in state, federal, and managed care requirements
Responsibilities When Assigned to Clinical Operations
Directs CCHP’s day-to-day clinical operations within & between all Clinical Operations Departments, including, but not limited to: Utilization Management, Case Management, Clinical Quality Auditing, and Advice Nurse Unit
Coordinates inter-departmental activity to synergize operational impact
Develops and implements clinical policies and workflows that improve access, efficiency, and member experience
Coordinates with providers, community partners, and county divisions to meet member needs
Leads efforts to improve operational efficiency in clinical workflows, ensuring members receive the right care, at the right time, in the right setting
Monitors and evaluates program performance to meet regulatory requirements and achieve positive health outcomes
Supports staff development and mentors a team of nurses, social workers, and health educators
Serves as a key liaison between CCHP clinical teams, community-based organizations, and other County departments
When Assigned to Utilization Management
Oversees utilization management (UM) functions including prior authorization review, retrospective review, concurrent review, and discharge planning
Supervises UM nurses and staff, ensuring adherence to medical necessity standards and regulatory requirements
Collaborates with Medical Directors and Chief Medical Officer
Monitors UM operations for timeliness, compliance, and alignment with evidence-based practice guidelines
Ensures UM processes comply with all Medi-Cal (DHCS), Medicare (CMS), DMHC, and NCQA requirements
Collaborates with hospitals, facilities, and providers to support timely discharges, reduce readmissions, and improve care coordination
Develops and refines UM policies, workflows, and decision-making standards to align with evidence-based practices and maintain regulatory compliance
Prepares and presents UM reports to internal leadership, external regulators, and governing committees
Additional Responsibilities
Directing and supervising clinical and administrative staff in either clinical operations or utilization management
Providing clinical oversight, coaching, and mentoring to team members
Developing and implementing operational programs, policies, and workflows
Ensuring compliance with DHCS, DMHC, CMS, and other regulatory requirements
Coordinating with providers and partners to improve care access and outcomes
Preparing reports and documentation for leadership, regulators, and accrediting bodies
Why you might love this job
You will play a vital role in ensuring Contra Costa residents receive timely, high-quality care
You will lead teams that make a real difference in members’ health and well-being
You will work in a mission-driven, equity-focused organization with a supportive leadership team
We offer generous benefits and a competitive retirement package
Challenges you might face
Navigating complex regulatory requirements while balancing operational needs
Managing high-volume workloads and competing priorities
Leading staff through change in a dynamic healthcare environment
Competencies Required
Critical Thinking & Problem Solving:
Analytically and logically evaluating information, identifying solutions, and making sound decisions
Legal & Regulatory Navigation : Interpreting and applying compliance requirements
Leadership & Accountability : Guiding staff to achieve shared goals
Strategic Thinking : Balancing short-term operational demands with long-term priorities
Systems Thinking : Connecting clinical operations or utilization management with overall plan strategy
To read the complete job description, please refer to the recruitment materials. The eligible list established from this recruitment may be used to fill future openings for up to 6 months.
License Required:
Candidates must possess and maintain throughout the duration of employment: a current, valid, and unrestricted Registered Nurse license issued by the California Board of Registered Nursing.
Applicants are required to attach a copy of their license and transcripts to their application.
Education:
Possession of a Master’s Degree in nursing, hospital or health care administration, or a closely related field, from an accredited college or university.
Experience : Five (5) years of full-time experience, or its equivalent, as a Registered Nurse, Utilization Review Nurse, Discharge Planner, Case Management Nurse, or a Telephone Triage Registered Nurse in a healthcare or managed care setting (e.g. Preferred Provider Organization, Managed Care Organization, or Health Maintenance Organization), at least one (1) year must have been at a supervisory level.
Substitution : Possession of a Bachelor’s Degree in one of the fields noted above plus two (2) additional years of supervisory experience of the type noted above may be substituted for the Master’s Degree. There is
no
substitution for the one (1) year of supervisory experience.
Possession of a Certified Case Manager (CCM) certification issued by the Commission for Case Manager Certification may be substituted for one (1) year of the required experience.
Application and selection
Application Filing and Evaluation:
Applicants will be required to complete a supplemental questionnaire at the time of application. Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.
Training & Experience Evaluation:
Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated. The responses to the supplemental questions, at the time of filing, will be evaluated to determine each candidate's relevant education, training, and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)
For recruitment questions, please contact Health Services Personnel, Recruitment Team at Exams@cchealth.org. For any technical issues, please contact the Government Jobs’ applicant support team for assistance at +1 855-524-5627.
The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.
Equal Employment Opportunity It is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.
#J-18808-Ljbffr