Outpatient Nurse Care - LPN Required - Waipahu, HI
WellCare - Honolulu, HI

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1300266

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, Florida, WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. For more information about WellCare, please visit the Company’s website at www.wellcare.com.

Our History: Founded in 1985 with three associates, WellCare grew to more than 800 associates and 467,000 members in Florida, New York and Connecticut by 2002. In 2004, the company acquired Harmony to enter the Midwest and became publicly traded. By 2006, WellCare served 2.2 million members as it became a national prescription drug plan provider and the largest Medicaid plan in Georgia. WellCare expanded its services when it began offering Medicaid managed care plans in Ohio and Missouri in 2007, and Medicare managed care plans in Texas and New Jersey in 2008. Additional growth followed when the company was chosen to serve Hawaii’s Medicaid program for the aged, blind or disabled in 2009, and in 2011 when it was selected to serve Kentucky’s Medicaid program. Today, WellCare has more than 3,900 associates and approximately 2.4 million members nationwide.

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. 2

nd

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

HI-Oahu-Honolulu

Is a relocation package available?

No

WellCare - 20 months ago - save job
About this company
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WellCare knows that to get well, all you need is a little care. WellCare Health Plans provides managed-care administrative services to...