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*Inpatient Care Nurse - LPN/RN - Office Setting (Tampa, FL)-1404764

IBM Type Full time Posted 4/23/2014
Salary - n/a - Starts - n/a -
FL - Florida (All) - Tampa Referral - n/a -    
About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. The company serves approximately 3.3 million members nationwide as of January 1, 2014. The company employs more than 5,100 nationwide. For more information about WellCare, please visit the company's website at www.wellcare.com. A Fortune 500 company traded on the New York Stock Exchange (symbol: WCG).

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.
 Oversees utilization management activities by assessing the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan.

Essential Functions:
  • Telephonically reviews medical information in order to determine the medical necessity of continued stay according to review standards. Determines whether treatments are consistent with member's diagnosis and appropriate level of care.
  • Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
  • Determines medical necessity and length of stay based on the consistent application of CMS criteria, Interqual criteria, and Clinical Coverage Guidelines and communicates with Medical Directors for those reviews that fall outside of approvals.
  • Assesses and coordinates simple discharge planning (short-term rehabilitation, homecare etc) with physicians, caregivers and ancillary providers to support the member’s continuity of care needs.
  • Interacts with facility discharge planners/utilization management team to coordinate medical treatment plan, and identifies opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care.
  • Identifies members at high risk for complicated medical treatment plans, and/or repeat admissions potential and refers them to the appropriate case and disease management teams.
  • Coordinates authorization and/or delivery of post-acute care services, including, but not limited to referrals to case and disease management, home health, medical equipment, skilled nursing facilities and other community based services.
  • Identifies quality of care issues, and reports to appropriate health plan Quality department representative. Ability to follow and apply all necessary regulatory requirements for assigned market.
  • Oversees the appropriate utilization management of services requested.
  • Assists with implementation of healthcare initiatives in market.
  • Assists in implementation of specific strategies that improve the quality and outcomes of care in market.
  • Performs other duties as assigned.
Additional Responsibilities:
 Candidate Education:
  • Required          A High School or GED
  • Preferred          A Bachelor's Degree in a related field
Candidate Experience:
  • Required           2+ years of experience in a clinical setting with general nursing exposure in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
  • Preferred           Other Care management experience in a managed health care setting
Candidate Skills:
  • Intermediate       Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
  • Intermediate       Ability to multi-task
  • Intermediate       Demonstrated time management and priority setting skills
  • Intermediate       Demonstrated interpersonal/verbal communication skills
  • Intermediate       Demonstrated written communication skills
  • Intermediate       Ability to create, review and interpret treatment plans
  • Intermediate       Demonstrated problem solving skills
  • Intermediate       Knowledge of healthcare delivery
  • Intermediate       Ability to effectively present information and respond to questions from families, members, and providers
  • Intermediate       Ability to effectively present information and respond to questions from peers and management
Licenses and Certifications:
  • Required          Licensed Practical Nurse (LPN)
Technical Skills:
  • Required          Intermediate       Microsoft Excel Proficient in Microsoft Office such as Excel, Word and Outlook
  • Required          Intermediate       Microsoft Word
  • Required          Intermediate       Microsoft Outlook
  • Required          Intermediate       Healthcare Management Systems (Generic) Ability to use health services management systems

Primary Location


Is a relocation package available?