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Inpatient Care Nurse

Wellcare - Tampa, FL

Inpatient Care Nurse','1704353','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at or view our videos at 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. Reports to: Sup, Clinical Care

Department: HS-Inpatient Care Management

Location: Hamden, CT.

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:A license in one of the following is required:

Required Licensed Practical Nurse (LPN) Technical Skills:

Required Beginner Microsoft Excel Proficient in Microsoft Office such as Excel, Word and Outlook

Required Beginner Microsoft Word

Required Beginner Microsoft Outlook

Required Beginner Healthcare Management Systems (Generic) Ability to use health services management systems Languages:

','US-FL-Tampa','8735 Henderson Rd','','Tampa','33634','US-CT-Hamden','','No','No','Inpatient Care Nurse'

18 days 9 hours ago



Inpatient Care Nurse Wellcare - Tampa, FL, United States


Location: Tampa, FL

Company Profile:
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.