Essential Functions: Travels daily to assigned facilities to talk with members and physicians regarding the status and treatments within each case. Based on travel schedule and individual member\u2019s situation, conducts onsite and\/or telephonic concurrent review of members in assigned facilities to validate medical necessity of facility admissions. Provides authorization to facilities using standard clinical criteria guidelines in conjunction with clinical judgment to determine the needed care required within the patient's individualized created care plan. Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and\/or hospitals, to share information and collaboratively establish acute and post-acute treatment plans for hospitalized members. Interacts with treating physicians and health plan medical directors to evaluate medical treatment plan, and assesses opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care. Documents clinical updates, authorizations and referrals in the health plan medical management system adhering to health plan documentation standards. Utilizing clinical judgment, assesses and evaluates members at risk for complicated medical comorbidties, and\/or repeat admissions potential, and determines individualized care plan for communication and interventions to promote successful discharge and post-acute care treatment plan. Conducts patient interviews and clinical assessments through personal visits, and using clinical judgment, determines appropriate level of interventions and patient's need for follow up care. Coordinates authorization and\/or delivery of post-acute care services, including, but not limited to referrals to case and disease management, home health, medical equipment, skilled nursing facilities and other community based services. Provides members with educational resources to enhance their ability to access health care services, including health plan contacts, primary care physician and other pertinent health care provider contacts. Facilitates referrals for post-discharge follow up with appropriate professional providers and support services (i.e. transportation) to ensure that members are able to access medically necessary services after discharge. Complies with all health plan and facility based regulations regarding HIPAA and patient safety and security. Identifies quality of care issues, and reports to appropriate health plan Quality department representative. Performs special projects as assigned. Additional Responsibilities: Nurse will be based out of home, with travel required daily to assigned hospitals and facilities; Frequent travel required to regional health plan office. Valid driver\u2019s license, without restrictions, is required. Qualifications Candidate Education: Required A High School or GED Preferred A Bachelor's Degree in a related field Health Services or Nursing Candidate Experience: Required 3 years of experience in a clinical setting with general nursing exposure in the following: E\/R critical care, discharge planning, bedside care, and\/or acute care facility. Required 3 years of experience in applying nursing judgment to make clinical decisions with minimal supervisory or oversight Preferred 1 year of experience in Managed Care Candidate Skills: Intermediate Ability to analyze information and covert related activities into a comprehensive work plan Intermediate Ability to work in a fast paced environment with changing priorities Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Ability to effectively present information and respond to questions from families, members, and providers Intermediate Ability to create, review and interpret treatment plans Intermediate Demonstrated written communication skills Intermediate Ability to influence internal and external constituents Intermediate Ability to represent the company with external constituents Intermediate Demonstrated interpersonal\/verbal communication skills Intermediate Demonstrated customer service skills Intermediate Knowledge of healthcare delivery Intermediate Knowledge of community, state and federal laws and resources Licenses and Certifications: A license in one of the following is required: Required Licensed Registered Nurse (RN) Technical Skills: Required Intermediate Microsoft Excel Required Intermediate Microsoft Outlook Required Intermediate Microsoft Word Required Intermediate Healthcare Management Systems (Generic) Languages: Required English Preferred Spanish
Website : http://www.wellcare.com
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.