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Wound Care UM RN

Company: Elevance Health
Location: Mason
Posted on: May 15, 2024

Job Description:

Wound Care UM RN
Location: Remote, within 50 miles of a pulse point
Hours: An 8 hour shift Monday - Friday between the hours of 8 am - 7 pm CST.
A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve. The Wound Care UM 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. You will oversee members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound, and identify and monitor delivery of home-based services, respond to members total health needs and ensures the highest quality of continuity of care.
How you will make an impact:



  • 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 members medical records discussion with the members 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 decrease 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 care givers 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.


    Minimum Requirements:


    • Requires RN license and 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 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.


      Preferred Skills, Capabilities and Experiences:


      • Home health experience preferred.


      • 1 year of Utilization Management experience preferred.


      • Multi-State/Compact Nursing License strongly preferred.


        ** For candidates working in person or remotely in the below locations, the salary* range for this specific position is $34.54 to $62.17
        Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ
        In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

        • The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Keywords: Elevance Health, Middletown , Wound Care UM RN, Healthcare , Mason, Ohio

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