Wound Care Utilization Management RN

Wound Care Utilization Management RN

Location:

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. Please note that per our policy on 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).

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.

• 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.

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

Job Level: Non-Management Non-Exempt Workshift:
Job Family: MED >
Licensed Nurse

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit…