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Role Description

The Wound Care Utilization Management 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 member's total health needs, and ensures the highest quality of continuity of care.

• 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 member's medical records, discussion with the member's 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 decreases 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, caregivers, 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.

Qualifications

• 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.

Requirements

• 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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).