Wound Care Utilization Management RN

Anticipated End Date:

Position Title:

Wound Care Utilization Management RN

Job Description:

Wound Care Utilization Management RN

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 center-connecting 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.

Virtual - This role enables associates to work virtually full-time, with the exception of 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.

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 an accommodation is granted as required by law.

Work Shift

Hours:

Monday through Friday, 8:00AM to 4:30PM (CST).

The Wound Care UM 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.

How you will make an impact:

* Develops coordinated collaborative care plans with all involved providers.

* Reviews Home based services for clinical appropriateness of the continued care.

* Performs reviews telephonically using the members medical records discussion with the members physician and/or discussion with Home health agency staff.

* Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care.

* Promotes healing and decrease home care utilization.

* Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.

* Requests additional clinical information from members care providers as necessary.

* Facilitates timely discharges and transfers based on individual needs and care requirements.

* 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.

* Monitors cost-effective use of resources and uses 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 a HS diploma or equivalent and a 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.

* Current active valid 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 program such as WOCN or ABWM and ostomy experience is also required.

Preferred Skills, Capabilities and Experiences:

* WOCNCB certification preferred. Home health experience preferred.

* 1 year of Utilization Management experience preferred.

* Compact license would be preferred but not required for consideration.

* Prior Home Health experience preferred.

* Intermediate knowledge of MS Office Suite products preferred.

For candidates working in person or virtually in the below location(s), the salary
* range for this specific position is $39.34/hr. to $67.44/hr.

Locations:
California, District of Columbia (Washington, DC);
Illinois, New Jersey, Massachusetts and Nevada.

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…