Represents WellCare at assigned facilities to provide concurrent review, discharge planning and clinical evaluations of members for Case Management needs during face-to-face interaction. Identifies members with high risk medical conditions that will require complicated medical treatments for determination of individualized post-acute plan of care to reduce the risk of complications and/or readmissions. Works collaboratively with providers and facilities to determine, coordinate and authorize post-acute care services and will provide referrals to clinical and social support services, including but not limited to, case/disease management, other providers within the plan's network and with community based resources.
Location: Bronx, NY- Onsite assigned to Montefiore Hospital
Reports to: Director, Utilization Management- Tampa FL Corporate
Type: Salary / Exempt
Travel Required for onsite visits to location above.
- 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's 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.
- 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's license, without restrictions, is required.
- Required A High School or GED
- Preferred A Bachelor's Degree in a related field Health Services or Nursing
- 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
Licenses and Certifications:
- 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
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Required Intermediate Healthcare Management Systems (Generic)
- Required English
- Preferred Spanish