Responsible for performing pre-certification 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 complex wound needs 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.

Primary duties may include but are not limited to:

• Develops coordinated collaborative care plans with all involved providers. Reviews Home based services for clinical appropriateness of the continued care.

• Performs reviews telephonically using the members medical records discussion with the members physician and/or discussion with Home health agency staff.

• Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care.

• Promotes healing and decrease home care utilization.

• Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.

• Requests additional clinical information from members care providers as necessary.

• Facilitates timely discharges and transfers based on individual needs and care requirements.

• Educates patients to help them understand their health choices and 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 uses 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.

Requirements:

• Requires a HS diploma or equivalent and a minimum of 5 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 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 program such as WOCN or ABWM and ostomy experience is also required.

• For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

Preferred Skills, Capabilities and Experiences:

• WOCNCB certification preferred.

• Home health experience preferred.

• 1 year of Utilization Management experience preferred.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $36.27 - $49.65

Locations:  Nevada; Washington State, California

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.