Wound Care Utilization Management Rn

Description

A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

Training schedule is 8a-4:30p CST, M-F

Work schedule is an 8 hr shift between 7A-7P CST, M-F

The Wound Care Utilization Management RN is responsible for performing pre-certification certification and/or authorization activities for Home Health Services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services responds to a members total health needs and ensures the highest quality of continuity of care.

Primary duties may include but are not limited to:

• Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.
• Monitors cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed.
• Facilitates timely discharges and transfers based on individual needs and care requirements.
• Reviews Home based services for clinical appropriateness of the continued care.
• Certifications relevant to wound care such as WOCN or CWS required
• Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care.
• Requests additional clinical information from members care providers as necessary.
• Develops coordinated collaborative care plans with all involved providers.
• Promotes healing and decrease home care utilization.
• Performs reviews telephonically using the members medical records discussion with the members physician and/or discussion with Home health agency staff.
• Refers requests that do not meet coverage guidelines criteria to Physician for review.
• Educates patients to help them understand their health choices and assists them in making informed decisions about their health care.
• Serves as an information resource to patients health care professionals facilities health plan representatives care givers and family members.
• Uses clinical judgment in authorizations that fall outside of guideline parameters.

Requirements:

• Current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required.
• Home health experience For the Wound Care Connect program, in addition to Wound Care Certification requirements above, Ostomy training through accredited program such as WOCN or ABWM and ostomy experience is also required.
• RN license
• Minimum of 5 years of experience in a variety of health care settings; or any combination of education and experience which provides an equivalent background.

Preferences:

• 1 year of Utilization Management experience
• WOCNCB certification

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $28.38 to $40.80

Locations: California; Colorado; Nevada; Washington State

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

For URAC accredited areas the following applies:

• Current, active, unrestricted license or certification as a physical therapist assistant, occupational therapist assistant, or speech language pathologist assistant in applicable state or territory of the United States. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review.
• Requires current, active, unrestricted license in occupational, speech, or physical therapy to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.

For URAC accredited areas, the following professional competencies apply:

• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.