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*Outpatient Nurse Care - LPN/RN - Office Setting (Tampa, FL)-1402090

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.
 
Description
 
Oversees the utilization management activities by evaluating 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:
  • Reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria. 
  • Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
  • Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
  • Identifies apporpriate clinical settings for services being requested.
  • Identifies and refers cases appropriate for case management.
  • Identifies potential quality of care issues and refers to Quality Department.
  • Ability to follow and apply all necessary regulatory requirements for assigned market.
  • Determines 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.
  • Performs other duties as assigned.
 
Qualifications
 
Education:  License Practical Nurse (LPN).        
 
Experience:  2+ years clinical experience in acute clinical/surgical experience, current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews.  Care management experience in a managed health care setting preferred.    
 
Licenses/Certifications:  Licensed Practical Nurse with current, unrestricted license       
 
Special Skills (e.g. 2nd language): 
Demonstrates effective communication methods to assist in training and to relate effectively to upper management
Strong decision-making and administrative skills
Strong knowledge of practice guidelines
Ability to work independently, handle multiple assignments and prioritize workload 
Demonstrates high level time management and priority setting
Strong oral and written communication skills
Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position.
Ability to review and interpret treatment plans
Demonstrated ability to lead others
  •  Technical Skills/Requirements:  Proficient in Microsoft Office including Excel, Word and Outlook Express

Primary Location

 FL-Tampa

Is a relocation package available?
 No