Senior Medical Management Nurse - VCHCP

Full Job Description

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) that offers an extensive range of benefits and low out-of-pocket expenses. Established as a cost-effective and practical option for providing health care services to County employees and their covered dependents. VCHCP is dedicated to excellence in service and care.

As a member of the Quality Management team in VCHCP, you'll play a vital role in ensuring that patient care meets the highest standards of safety, effectiveness, and satisfaction. Our goal is to foster a culture of excellence and accountability, where continuous feedback and improvement drive safer, more efficient, and patient-centered care.

Under general direction, the Senior Medical Management Nurse is responsible for performing utilization review, case management, and quality improvement functions to ensure that members receive appropriate, cost-effective, and high-quality care. The role involves conducting 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 position plays a key role in promoting optimal health outcomes while maintaining adherence to health plan policies, benefits, 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.

What We Offer
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 completion of an associate's degree, 3.5% for completion of a bachelor's degree, or 5% for completion of a graduate's degree.
• Bilingual Incentive: Incumbents may be eligible for bilingual incentive depending upon operational need and certification of skill. Proficiency levels by exam are $0.69/hour (Level I), $1.00/hour (Level II), or $1.32/hour (Level III).
• Certification Pay: $0.813 per hour based on scheduled work week hours for each qualified certification up to a maximum of five (5) certifications. One of the five certifications may be paid at $2.00 per hour for a National Certification. List provided in the MOA, Exhibit 9.
• Continuous County Service Incentive Pay: 1% for 7 years, 1.25% for 12 years and 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 the Section 457 Plan. This position is eligible for up to a 2% match on your 401(k) contributions.
• Pension Plan: Participation in the County's defined benefit pension plan. If eligible, you may establish reciprocity with other public retirement systems such as CalPERS.
• To learn more about the benefits, please follow the link below: CNA_MOA_2023-2028.pdf (ventura.org)

PAYROLL TITLE: Senior Registered Nurse – Ambulatory Care

DISTINGUISHING CHARACTERISTICS: The Senior Registered Nurse-Ambulatory Care series is distinguished from other nursing classifications in that they are assigned to Ambulatory Care programs affiliated with the Ventura County Medical Center, and requires that incumbents demonstrate advanced competency skills and knowledge specific to the specialty areas (i.e. Quality Management, family care, women’s services, pediatrics, infusion/oncology, surgery/orthopedic, etc.). The incumbents are expected to work at the full scope of their licensure, with a decreasing amount of supervision commensurate with their experience. The regular and senior levels are distinguished by experience and leadership assignments.

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 Quality Management (QA) with the Ventura County Health Care Plan.

TENTATIVE SCHEDULE
OPENING DATE: November 06, 2025
CLOSING DATE: Continuous and may close at any time; therefore, the schedule for the remainder of the process will depend upon when we receive enough qualified applications to meet business needs. It is to your advantage to apply as soon as possible.
(Previously: November 20, 2025, at 5:00 p.m.)

Requirements

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, the treatment team, patients, and families in 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 analysis 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.

Qualifications

These are entrance requirements to the examination process and ensure 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.

DESIRED
Any of the following:

• 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.

KNOWLEDGE, SKILLS, and ABILITIES:
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.

Skills in the following:

• Problem solving/conflict resolution;
• Organization to manage all aspects of a client’s case.

Working ability to:

• 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.

Additional Information

FINAL FILING DATE: This is a continuous recruitment and may close at any time; therefore, apply as soon as possible if you are interested in it. Your application must be received by County of Ventura Human Resources no later than 5:00 p.m. on the closing date.

(Previously: Your application must be received by County of Ventura Human Resources in Ventura, California, no later than 5:00 p.m. on Thursday, November 20, 2025.)

To apply on-line, please refer to our web site at hr.venturacounty.gov. If you prefer to fill out a paper application form, please call (805) 677-5184 for application materials and submit them to County of Ventura Human Resources - Health Care Agency, 646 County Square Drive, Ventura, CA 93003.

Note to Applicants: 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 - 100%: All applications will be reviewed to determine whether or not the stated requirements are met. A score of 70 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 exam 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.

For further information about this recruitment, please contact Vivian Merida via email at Vivian.Merida@venturacounty.gov or by telephone at (805) 677-5231.

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.