Inpatient Care Nurse RN

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.

DEPARTMENT: Health Services-Inpatient Care Management

REPORTS TO: Supervisor, Clinical Care

Essential Functions:

  • 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.
Additional Responsibilities:
    Candidate Education:
    • Required a High School or GED
    • Preferred a Bachelor's Degree in a related field
    Candidate Experience:
    • Required 2 years of experience in acute medical hospital environment (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
    Candidate Skills:
    • 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)
    Technical Skills:
    • Required Beginner Microsoft Excel
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Healthcare Management Systems (Generic)
    Languages:

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. 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.