Wound Care Utilization Management Nurse

POSITION DESCRIPTION:

The experienced wound care nurse will join our team of Utilization Management professionals. The WOC Nurse will monitor and authorize home care services for complex wound members via electronic and telephonic modalities. You will work with our home health agency partners to ensure that there is delivery of reasonable, necessary and clinically appropriate services related to the wound care and any other co-morbidities. Through the WOC Nurse’s ongoing management, the organization will improve healthcare outcomes while reducing the costs associated with wound care patients.

Primary duties include, but are not limited to:

ESSENTIAL FUNCTIONS:

  • The wound care nurse will review pre-service, concurrent and retrospective authorizations/claims for skilled nursing visits for wound care patients and requests for any other skilled disciplines that may be needed in the home. (PT, OT, ST, MSW, HHA)
  • Assess the needs of wounds from surgery, accidents and disease states to determine intermediate and long-term treatment plans for the members.
  • Make determination of the need for continued skilled home health services by reviewing clinical documentation, pictures and measurements in accordance with Medicare and MCG guidelines.
  • Maintains accurate records of authorizations and communications with providers, members and payer plans pertaining to authorization and/or denial process.
  • Review, communication and collaboration with the wound care clinic (as applicable) home health agency, physician, nurse, patient, caregiver and Medical Director.
  • Education to patient and caregivers on best practices to promote healing and excellent outcomes.
  • Coordinate with WCC, physician and home care agencies to ensure current plan of care is working for member’s best interest and recovery process.
  • Monitor patient progress and satisfaction.
  • Facilitates communication and provides ongoing customer services support to payer plan case managers, patients, physician, provider staff and internal team members.
  • Provide education and training for in-house team members.
  • Prepares and submits any required status or summary reports in a timely manner.
  • Work collaboratively and communicate effectively to provide additional support for other departmental tasks and duties.
  • Acts as a team player to help develop and reinforce colleagues understanding of necessary authorization/ denial requirements and supporting documentation.
  • Ensure that inquiries and requests for services are addressed in a timely manner and within contract compliance.
  • Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
  • Other clinical duties as required.

QUALIFICATIONS

BSN degree (preferred) • Wound Care Certification Required as a CWCN, CWOCN OR CWS • Current Arizona state licensure as a registered nurse (RN or LPN) with no restrictions • Prior experience in home health required • Utilization Management/review experience preferred.

KNOWLEDGE AND EXPERIENCE:

5 years of wound care focus and experience.

2 years home health experience required.

2 years managed care, utilization review/management or case management experience preferred

Computer skills such as MS Office products – Outlook, Excel, Word, Adobe and the ability to toggle within multiple medical management systems

Job Category: Clinical
Job Type: Full Time
Job Location: Phoenix Office

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