Wound Care Utilization Management RN

Wound Care Utilization Management RN

Wound Care Utilization Management RN

Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the centerconnecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health.

Work Shift Hours: Monday through Friday, 8:00AM to 4:30PM (CST). No weekends, with major holidays off.

The Wound Care Utilization Management RN will be responsible for performing pre-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 wounds need 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.

How you will make an impact:

• Develops coordinated collaborative care plans with providers.
• Reviews Home based services for clinical appropriateness of continued care.
• Performs reviews telephonically/virtually/remotely utilizing the members medical records and/or discussion with the members physician and/or discussion with Home Health agency staff.
• Connects with the home care agency and ordering physician(s) to discuss the member's plan of care for wound care.
• Promote healing and decreased home care utilization.
• Responsible for certification determinations and providing authorizations to referring physician and home health care provider as necessary.
• Requests additional clinical information from members' care providers as necessary.
• Facilitates timely discharges and transfers based on individual needs and care requirements.
• May educate patients to help them understand their health choices and may 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.
• Monitors cost-effective use of resources and use clinical expertise to make recommendations for alternate resources as needed.
• Refers requests that do not meet coverage guidelines criteria to Physician for review.
• Uses clinical judgment in authorizations that fall outside of guideline parameters.

Minimum Requirements:

• Requires AS in nursing and a minimum of 3 years of experience in a variety of health care settings; or any combination of education and experience which provides an equivalent background.
• Current, active, valid and 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.
• Certifications relevant to wound care such as WOCN or CWS required.
• For the Wound Care Connect program, in addition to Wound Care Certification requirements above, Ostomy training through accredited programs such as WOCN or ABWM and Ostomy experience is also required.

Preferred Skills, Capabilities and Experiences:

• WOCNCB certification preferred.
• Home health experience preferred.
• Minimum of 1 year of Utilization Management experience preferred.
• Compact license preferred.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $39.34/hr. to $56.20/hr.

Location(s): California, Illinois, Massachusetts, Nevada and New Jersey.