Oct 19, 2019
WellCare Health Plans Oversees the utilization management activities by evaluating the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan. Reports to: Manager of Prior Authorization Department: New Jersey Care Management Location: Newark, NJ Essential Functions: Reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria. Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized. Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information. Identifies appropriate clinical settings for services being requested. Identifies and refers cases appropriate for case management. Identifies potential quality of care issues and refers to Quality Department. Ability to follow and apply all necessary regulatory requirements for assigned market. Determines appropriate utilization management of services requested. Assists with implementation of healthcare initiatives in market. Assists in implementation of specific strategies that improve the quality and outcomes of care. Performs other duties as assigned. Additional Responsibilities: Candidate Education: Required A High School or GED Candidate Experience: Required 2 years of experience in Nursing Preferred 1 year of experience in Performing utilization reviews Preferred Other Experience performing UM in a managed care setting Candidate Skills: Intermediate Ability to communicate and make recommendations to upper management Intermediate Ability to work independently Intermediate Ability to multi-task Intermediate Ability to work in a fast paced environment with changing priorities Intermediate Demonstrated time management and priority setting skills Intermediate Demonstrated written communication skills Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Ability to create, review and interpret treatment plans Intermediate Knowledge of healthcare delivery Intermediate Ability to effectively present information and respond to questions from families, members, and providers Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Other Strong decision-making and administrative skills Licenses and Certifications: A license in one of the following is required: Required Licensed Practical Nurse (LPN) Technical Skills: Required Beginner Microsoft Excel Required Beginner Microsoft Word Required Beginner Microsoft Outlook Required Beginner Healthcare Management Systems (Generic) Languages: About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.
Professional Diversity Network Newark, NJ, USA Full-Time