Department: Health Services-Inpatient Care Mgmt
Reports to: Supervisor, Clinical Care
Location: Tampa FL, Atlanta, GA or Louisville, KY
WellCare has an exciting opportunity for a Skilled Nursing Facility (SNF) Nurse Reviewer to join our team! The selected candidate will review the medical necessity for SNF admissions and continued stays. Our ideal candidate is an LPN, has excellent time management and organizational skills, solid ability to communicate effectively with doctors/providers and a strong desire to move processes forward in a timely manner. This position can be located in either Tampa, FL, Atlanta, GA or Louisville, KY. Must be local to WellCare office. PLEASE NOTE: This position is work from work for the first 90 days. Candidates who meet metrics/standards will then be able to work from home. This is a full-time, direct hire position with an outstanding benefits package.
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.
Additional Responsibilities: Candidate Education:
- 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 judgement 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 judgement 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 critieria 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.
- Required A High School or GED
- Preferred A Bachelor's Degree in a related field
- 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
Licenses and Certifications:
- Intermediate Other 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 Other Demonstrated understanding of MCG or Interqual guidelines
A license in one of the following is required:
- Required Licensed Practical Nurse (LPN)
- Required Beginner Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)