SNF Nurse Reviewer

Performs utilization review assessing medical necessity and level of care for skilled nursing facility admissions by systematically evaluating clinical information, criteria and quality using nursing judgment for initial and continued stay reviews. Maximizes the appropriate care that correlates to the member's benefit plan. Adheres to compliance requirements.

DEPARTMENT: Inpatient Care Management

REPORTS TO: Supv., Clinical Care

NOTE: Position will work remotely from home.

Essential Functions:

  • Performs utilization review assessing medical necessity and level of care for skilled nursing facility admissions by systematically evaluating clinical information, criteria and quality using nursing judgment for initial and continued stay reviews. Maximizes the appropriate care that correlates to the member's benefit plan. Adheres to compliance requirements. .
  • Evaluates and reviews clinical information submitted telephonically, electronically or in writing to determine medical necessity and appropriate level of care according to established guidelines and processes.
  • Use of nursing judgment to determine whether treatments are consistent with member's diagnosis and clinical needs.
  • Based on an evaluation of evidenced based guidelines, prepares cases for review by medical director when available information exceeds the limits of what the SNF Nurse Reviewer can approve or when criteria are not met.
  • Evaluates clinical information to identify and present appropriate cases during rounds. This includes identification of members at high risk for complicated medical treatment plans, readmissions potential, and admissions for potentially avoidable conditions.
  • Evaluates discharge planning needs and provides participating provider information to facilities.
  • Initiates interactions with providers and delegated entities to ensure progression of care and successful transition of members' care across treatment settings.
  • Ensures the services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
  • Performs other duties as assigned.
    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 a clinical setting from one of the following: Skilled Nursing Facility, Long Term Acute Care Facility and/or Inpatient Rehabilitation Facility
    Candidate Skills:
    • Intermediate demonstrated use of nursing judgment and critical thinking to review and interpret medical treatment plans.
    • Intermediate ability to multi-task
    • Intermediate demonstrated time management and priority setting skills
    • Intermediate demonstrated interpersonal/verbal communication skills
    • Intermediate knowledge of healthcare delivery
    • Intermediate ability to work independently
    • Intermediate demonstrated understanding of MCG or Interqual guidelines
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Licensed Practical Nurse (LPN)
    Technical Skills:
    • Required beginner Microsoft Excel
    • Required intermediate Microsoft Word
    • Required intermediate Microsoft Outlook
    • Required intermediate Healthcare Management Systems (Generic)

    Languages:

    • Bilingual English/Spanish helpful

    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.