Works collaboratively with supervisors, providers, community resources, and facilities to establish and implement processes to support delivery of effective utilization management. Coordinates assignments to manage daily census. Acts as clinical specialist and utilization management subject matter expert for complex situations. Provides mentoring and training to other inpatient utilization review nurses. Champions compliance requirements.
Telephonically reviews medical information in order to determine the medical necessity of continued stay according to review standards. Determines whether treatments are consistent with member's diagnosis and appropriate level of care.
Uses critical thinking to determine if treatments are consistent with member's diagnosis and clinical needs. Ensures services provided are within benefit plan and that appropriate contracted providers are utilized.
Identifies needed information. Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits.
Initiates interactions with providers regarding anticipated progression of care and transitions across treatment settings. Facilitates referrals for follow up providers and support services.
Evaluates clinical information to identify and present cases during rounds. This includes identification of members at high risk for complicated medical treatment plans, readmissions potential, and admissions for potentially avoidable conditions.
Prepares cases for review by medical director when condition or treatment plan varies from established guidelines.
Documents clinical updates, authorizations, and referrals in the health plan care management system adhering to health plan documentation standards.
Provides members and/or treating providers with resources to enhance their ability to access services.
Performs other duties as assigned.
Required A High School or GED
Preferred A Bachelor's Degree in a related field
Required 2 years of experience in Acute medical hospital experience (medical/surgical, emergency room, orthopedic, neurological care experience
Preferred 2 years of experience in UM, CCM, Clinical Criteria, or other nursing specialty certification
Preferred 2 years of experience in discharge planning
Intermediate Ability to work independently
Intermediate Ability to multi-task
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Ability to create, review and interpret treatment plans
Intermediate Demonstrated problem solving skills
Intermediate Knowledge of healthcare delivery
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to effectively present information and respond to questions from peers and management
Licenses and Certifications: A license in one of the following is required:
Required Registered Nurse (RN)
Required Beginner Microsoft Excel
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)
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.