Wound Care Utilization Management RN

The Elevance Health Companies, Inc.; Grand Prairie (TX); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Elevance Health is seeking a Wound Care Utilization Management RN to work primarily virtually with periodic in-person training sessions. The role requires an active RN license, WOCN or CWS certification, and at least 3 years in diverse health care settings.

The RN will coordinate care plans, review home-based services, and discuss plans of care with providers. Hybrid work arrangement applies, with in-person onboarding and ongoing collaboration across care teams.

Qualifications

• Requires ASN in nursing and active RN license.
• WOCN or CWS certification required.
• Ostomy training through accredited programs required.
• Minimum 3 years of health care experience in varied settings.

Responsibilities

• Develops coordinated collaborative care plans with providers.
• Reviews Home based services for clinical appropriateness of continued care.
• Performs reviews telephonically/virtually/remotely using medical records.
• Connects with home care agency and physicians to discuss plan of care.
• Promotes healing and decreased home care utilization.
• Responsible for certification determinations and authorizations.
• Requests additional clinical information from care providers as needed.
• Facilitates timely discharges and transfers based on needs.
• Educates patients to help them understand health choices.
• Serves as information resource to patients' care teams and family.
• Monitors cost-effective resource use and recommends alternatives.
• Refer requests not meeting guidelines to physician for review.
• Uses clinical judgment in authorizations outside guideline parameters.

Skills

Utilization Management

Home health experience

Compact license

Education

ASN in Nursing

RN license

WOCN or CWS certification

Ostomy training (WOCN/ABWM)

Job description

Wound Care Utilization Management RN

Location: This role enables associates to work virtually full-time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development. Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Work Shift Hours: Monday through Friday, 8:00AM to 4:30PM (CST).

How you will make an impact:

• Develops coordinated collaborative care plans with providers.
• Reviews Home based services for clinical appropriateness of continued care.
• Performs reviews telephonically/virtually/remotely utilizing the members medical records and/or discussion with the members physician and/or discussion with Home Health agency staff.
• Connects with the home care agency and ordering physician(s) to discuss the member's plan of care for wound care.
• Promote healing and decreased home care utilization.
• Responsible for certification determinations and providing authorizations to referring physician and home health care provider as necessary.
• Requests additional clinical information from members’ care providers as necessary.
• Facilitates timely discharges and transfers based on individual needs and care requirements.
• May educate patients to help them understand their health choices and may assists them in making informed decisions about their health care.
• Serves as an information resource to patients’ health care professionals, facilities, health plan representatives, care givers and family members.
• Monitors cost-effective use of resources and use clinical expertise to make recommendations for alternate resources as needed.
• Refers requests that do not meet coverage guidelines criteria to Physician for review.
• Uses clinical judgment in authorizations that fall outside of guideline parameters.

Minimum Requirements

• Requires AS in nursing and a minimum of 3 years of experience in a variety of health care settings; or any combination of education and experience which provides an equivalent background.
• Current, active, valid and unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required.
• Certifications relevant to wound care such as WOCN or CWS required.
• For the Wound Care Connect program, in addition to Wound Care Certification requirements above, Ostomy training through accredited programs such as WOCN or ABWM and Ostomy experience is also required.

Preferred Skills, Capabilities and Experiences

• Home health experience preferred.
• Minimum of 1 year of Utilization Management experience preferred.
• Compact license preferred.

Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.