Telephonically coordinates discharge planning for WellCare members to ensure a safe and effective transition from an inpatient setting to an appropriate lower level of care. Works closely with internal medical directors and concurrent review nurses to assess members' clinical and social needs to provide a stable/supportive post-acute care environment. Communicates effectively with members and their families, treating physicians, hospital staff, home care, DME, skilled nursing facilities and rehab providers to implement the care plan, including the coordination and authorization of services, referrals to internal WellCare programs such as case/disease management and behavioral health, and referrals to community based programs. May also provide transitional management (approximately 2 weeks or less) through member contacts after discharge to ensure that members' needs are met and services are available and accessed.
Department: 3078 - HS- Inpatient Care Mgmt
Manager Title: Dir. Utilization Mgmt
Additional Responsibilities:Candidate Education:
- Through internal communication with concurrent review nurses, medical directors and other internal departments, identifies members with high risk medical conditions that will require complicated medical treatments to establish an individualized post-acute plan of care to reduce the risk of complications and/or readmissions and enter the authorizations for needed services
- Conducts patient interviews and assessments through telephonic contacts to determine appropriate level of interventions and assesses patient needs for follow up care.
- Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and/or hospitalists, to share information and collaboratively establish post-acute treatment plans for hospitalized members.
- Interacts with WellCare medical directors, concurrent review nurses and case/disease managers to evaluate the medical treatment plan and identify 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 WellCare medical management system adhering to company documentation standards.
- 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 WellCare 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 members are able 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 the issue to the appropriate WellCare Quality representative.
- Performs special projects as assigned.
- Required A High School or GED
- Preferred A Bachelor's Degree in Nursing or related field
- Required 2 years of experience in clinical acute care position(s), preferably in home health, physicians office or public health
- Preferred 1 year of experience in current case management experience
Licenses and Certifications:
- Intermediate Ability to drive multiple projects
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to work independently
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Demonstrated negotiation skills
- 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
- Intermediate Ability to implement process improvements
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Required Beginner Microsoft Excel
- Required Beginner Microsoft Word
- Required Beginner Microsoft Outlook
- Required Beginner Healthcare Management Systems (Generic)
- Preferred Other Bilingual skills