Care Manager II RN Wound Nurse
Perform 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. Oversee members who have complex wound needs to determine if the member has the current wound care for the type of wound. Contact the home care agency and ordering physician to discuss changing the member plan of care for wound care. Promote healing and decrease home care utilization. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. When necessary, requests additional clinical information from member’s care providers. Refers requests that do not meet coverage guidelines criteria to Physician Review for a Level III Review. The care coordination component of the UM program is designed to identify and monitor delivery of home-based services in an efficient manner, responding to a member’s total health needs and ensure the highest quality of continuity of care.
DUTIES AND RESPONSIBILITIES:
Demonstrates Competency in the Following Areas:
- Develop coordinated, collaborative care plans with all involved providers.
- Review Home based services for clinical appropriateness of the continued care.
- Performs reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff.
- Facilitate timely discharges and transfers based on individual needs and care requirements.
- Educate patients to help them understand their health choices and assist them in making informed decisions about their health care.
- Serve as information resource to patients, health care professionals, facilities, health plan representatives, care givers and family members.
- Monitor cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed.
- Refer requests that do not meet coverage guidelines criteria to myNEXUS Physician for a Level III Review.
- Identifies themselves by name, title and company name on all telephone calls. Provides, upon request, information on specific UM requirements and processes
- Answers the telephone and provider and member requests in a timely and polite manner.
- Is responsible for authorizations to be completed within specified time frames in department policy. Proactively escalating those cases that are at risk of not being completed within department policy.
- Uses clinical judgment in authorizations that fall outside of guideline parameters.
- Distributes appropriate authorization letters to providers and members in compliance with department policies and time frames.
- Follows process for acquiring additional clinical information as needed for incomplete authorization requests.
- Consults with Team Lead or Clinical Manager if there are questions regarding the case meeting clinical criteria.
- Handles all member and provider complaints appropriately and escalates complaints to department team lead or supervisor for further action and resolution.
- Maintains and respects confidentiality of member/physician/personnel information.
- Follows department guidelines for accurate review and entry of authorization data into computerized database.
- Recognizes member safety issues and advocates for care in an environment that optimizes member safety and reduces the likelihood of medical/health care errors.
- Knowledgeable of current Medicare and Medicaid requirements, necessity and justification requirements.
- Maintains a good rapport with physicians, private insurance companies and government agencies.
- Maintains a good working relationship both within the department and with other departments.
- Consults other departments as appropriate to collaborate in member care and performance improvement activities.
- Participates in performance improvement activities for department and CQI activities.
- Accepts additional assignments willingly.
- Adheres to dress code, appearance is neat and clean.
- Completes annual education and licensure requirements.
- Maintains member confidentiality at all times.
- Reports to work on time and as scheduled, completes work within designated time.
- Follows all company policies related to time records.
- Completes in-services in a timely fashion.
- Attends monthly/annual reviews and department in-services, as scheduled.
- Attends at staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.
- Represents the organization in a positive and professional manner.
- Actively participates in performance improvement and continuous quality improvement (CQI) activities.
- Complies with all organizational policies regarding ethical business practices.
- Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.
- Registered Nurse; minimum of 5 years of experience in a variety of health care settings.
- Other specialty licenses or certifications relevant to wound care reviews; WOCN or CWS Certification Required, WOCNCB Certification preferred.
- Home health experience preferred.
- Current state registered nurse license.
- Ability to read and communicate effectively in English.
- Additional languages preferred.
- Basic computer knowledge such as Word and Excel.
- Excellent customer service and follow-up skills.
- Ability to sit for long periods and read monitors.
- Strong attention to detail.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.
- Pay Type Hourly