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*New York Onsite Inpatient Care Manager, RN

New YorkWellCare

Represents WellCare at assigned facilities to provide concurrent review, discharge planning and clinical evaluations of members for Case Management needs during face-to-face interaction. Identifies members with high risk medical conditions that will require complicated medical treatments for determination of individualized post-acute plan of care to reduce the risk of complications and/or readmissions. Works collaboratively with providers and facilities to determine, coordinate and authorize post-acute care services and will provide referrals to clinical and social support services, including but not limited to, case/disease management, other providers within the plan’s network and with community based resources.

Location: Bronx, NY- Onsite assigned to Montefiore Hospital

Reports to: Director, Utilization Management- Tampa FL Corporate

Type: Salary / Exempt

Travel Required for onsite visits to location above.

Essential Functions:

  • Travels daily to assigned facilities to talk with members and physicians regarding the status and treatments within each case. Based on travel schedule and individual member’s situation, conducts onsite and/or telephonic concurrent review of members in assigned facilities to validate medical necessity of facility admissions.
  • Provides authorization to facilities using standard clinical criteria guidelines in conjunction with clinical judgment to determine the needed care required within the patient's individualized created care plan.
  • Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and/or hospitals, to share information and collaboratively establish acute and post-acute treatment plans for hospitalized members.
  • Interacts with treating physicians and health plan medical directors to evaluate medical treatment plan, and assesses opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care.
  • Documents clinical updates, authorizations and referrals in the health plan medical management system adhering to health plan documentation standards.
  • Utilizing clinical judgment, assesses and evaluates members at risk for complicated medical comorbidties, and/or repeat admissions potential, and determines individualized care plan for communication and interventions to promote successful discharge and post-acute care treatment plan.
  • Conducts patient interviews and clinical assessments through personal visits, and using clinical judgment, determines appropriate level of interventions and patient's need for follow up care.
  • 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.
  • Provides members with educational resources to enhance their ability to access health care services, including health plan contacts, primary care physician and other pertinent health care provider contacts.
  • Facilitates referrals for post-discharge follow up with appropriate professional providers and support services (i.e. transportation) to ensure that members are able to access medically necessary services after discharge.
  • Complies with all health plan and facility based regulations regarding HIPAA and patient safety and security.
  • Identifies quality of care issues, and reports to appropriate health plan Quality department representative.
  • Performs special projects as assigned.
Additional Responsibilities:
  • Nurse will be based out of home, with travel required daily to assigned hospitals and facilities; Frequent travel required to regional health plan office. Valid driver’s license, without restrictions, is required.

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