Outpatient Care Nurse - LPN Required - Waipahu, HI - (Requisition Number: 1303465 at Honolulu

Job Description

DEPARTMENT NAME: Health Services
HIRING MANAGER: Senior Manager, Field Utilization Mgmt

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 members 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 appropriate 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.

Job Requirements

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. 2nd language):Demonstrates effective communication methods to assist in training and to relate effectively to upper managementStrong decision-making and administrative skillsStrong knowledge of practice guidelinesAbility to work independently, handle multiple assignments and prioritize workloadDemonstrates high level time management and priority settingStrong oral and written communication skillsAdvanced ability as a licensed professional to communicate on any level required to meet the demands of the position.Ability to review and interpret treatment plansDemonstrated ability to lead others

• Technical Skills/Requirements: Proficient in Microsoft Office including Excel, Word and Outlook Express

Country: USA, State: Hawaii, City: Honolulu, Company: WellCare Health Plans Inc..