Wound Care Utilization Management RN

Elevance Health; Mason (OH); Remote; USD 75,000 - 95,000; Full time

Job summary

Elevance Health is seeking a Wound Care Utilization Management RN to support pre-certification and authorization for Home Health Services. This role emphasizes remote work with essential in-person training sessions and a strong focus on care coordination and outcomes.

You will review clinical records, collaborate with providers and home health agencies, and determine appropriate wound care plans while maintaining cost-effective resource use and compliance with coverage guidelines.

Qualifications

• Active RN license required.
• WOCN or CWS wound care certification required.
• Utilization management and home health experience preferred.

Responsibilities

• Performs pre-certification and/or authorization for Home Health Services.
• Develops collaborative care plans with providers and home health agencies.
• Reviews clinical information to determine appropriateness of continued home-based wound care.
• Request additional information as needed to support eligibility and coverage decisions.
• Facilitates timely discharges and transfers based on patient needs.

Skills

RN license

WOCN/CWS

Utilization management

Home health experience

Education

AS in nursing

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).

TheWound Care UM RN is responsible for performing pre-certification and/or authorization activities for Home Health Services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have wounds need to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services responds to a members total health needs and ensures the highest quality of continuity of care..

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.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 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.