Wellmark - Des Moines Care Coordination Nurse in Des Moines, Iowa
Help us lead change and transform the member experience
The health care industry is changing, and Wellmark is working to help change it for the better. We recognize that our members deserve health care with a focus on quality. We also recognize that health care is complex. We’re embarking on a journey to help our members use and navigate the health care system in order to help them make clear, informed decisions, and we’re also ensuring that we take a team-centric approach when working with and in support of our members. The work that our diverse business and care teams are doing in collaboration with our health care partners will create these changes, all while working to minimize health care costs.
Use your strengths as Care Coordination Nurse
In this newly created role, you will provide utilization management service, transition of care, and care management support to members and health care providers. You’ll use your clinical knowledge/expertise to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information; and provide consultation and responses to utilization management requests. This work includes the proactive assessment and assistance for members with future care needs to help move them through the continuum of care and to utilize services and resources efficiently. You’ll also function as part of a multi-disciplinary care team to continuously look for ways to improve processes and maximize health dollars for our members.
Our strongest candidates are mission driven – they believe health care and the member experience can be better, and they are passionate about finding new ways to influence this work. They’re resourceful, resilient advocates who enjoy thinking critically and helping others navigate care plans. They have a knack for staying a few steps ahead in a dynamic environment, which delights those they support. Most importantly, they acknowledge that this is not work that can be done alone. They are collaborative in approach, develop deep partnerships, and value the expertise of others.
**This role requires the ability to work a flexible schedule with shifts between the core hours of 8:30 a.m. and 7:00 p.m. Monday-Friday and 9:00 a.m. to 5:30 p.m. on Saturday.
*Work from home order: The effects of COVID-19 have moved our employees to a work from home environment. This role will start out fully remote but will be expected to work from our office upon our return. The time in which we expect to return to our office is undetermined but will take place when it is safe to do so.
Completion of an accredited nursing program or licensed practical nursing program.
Active and unrestricted RN or LPN license in Iowa or South Dakota. Individual must be licensed in the state in which they reside.
4+ years of diverse clinical experience (e.g. acute care, outpatient, home health, etc.) that reflects 4+ years of direct clinical care to the consumer. Experience in utilization management or health insurance setting beneficial.
Previous experience working independently and managing an assigned caseload.
Strong verbal communication skills; influences action and facilitates crucial conversations regarding care with members, physicians, and care facilities.
Strong written communication skills, including accurate documentation of events within the care management platform; ensures quality and consistency by following guidelines and processes.
Commitment to service excellence and member advocacy; uses critical thinking and problem-solving skills to anticipate and act on member/provider needs.
Resourceful self-starter who demonstrates strong understanding of resources, processes and guidelines. Able to make independent decisions or recommendations under ambiguity.
Ability to organize and manage multiple priorities in a dynamic work environment where quality and/or production goals are measured. Commitment to timeliness, follow up, accuracy and attention to detail. Flexible and adapts to change.
Develops collaborative relationships with peers, team members and stakeholders; viewed as a trusted partner.
Maintains courtesy and professionalism when engaging with members, internal and external stakeholders.
Strong technical acumen; learns new systems quickly – e.g., Microsoft Office, clinical documentation platforms, etc.
Knowledge of regulatory standards and regulations – e.g., URAC, NCQA, HIPAA, PHI, confidentiality.
Completion of an accredited nursing program.
Active and unrestricted RN license in Iowa or South Dakota.
Certified Case Manager (CCM)
a. Provide members and health care providers with appropriate and timely prior approval (services, procedures, Wellmark Health Plan of Iowa Out of Network Referrals) by obtaining medical information necessary to make a clinical determination based on appropriate medical policy or criteria. Complete post service reviews for medical necessity and/or experimental/investigational.
b. Provide precertification and continued stay reviews and support to members while located in an acute health care facility, skilled or other facility level of care or home health care admissions. In collaboration with facility and member, facilitate transition of care planning needs. Proactively identify key issues and barriers to discharge; ensure development and facilitation of a timely discharge plan. Make referrals to Care Management for ongoing long-term needs.
c. Proactively identify barriers and gaps to care while designing, creating and managing unique, individualized care plans that ensure members/providers have good communication channels, that members receive appropriate care, that potential duplication of effort is avoided, and education is provided to help enable them to achieve the best possible health care goals.
d. Partner with members, members’ families, health care providers and community resources to coordinate and facilitate the care and services needed.
e. Actively engage members as participants in their unique care management plan and educate on their personal accountabilities and expected outcomes. Advise on included benefits and services that are appropriate for their current medical status, and how those benefits and services can positively impact not only their medical status, but also the total cost of care.
f. Work with health care provider staff in a courteous and professional manner in gathering medical information and facilitating discharge planning to ensure accurate diagnosis codes for documentation and reporting purposes. Influence, collaborate and negotiate with providers in an open, direct, and supportive manner to resolve conflicts, utilization review issues and alternative treatment setting options.
g. Process utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria (InterQual), and benefit information for internal/external customers within the timeframes described in the requirements. Interact with Wellmark Medical Director, as appropriate for services that do not meet medical criteria.
h. As a member of the interdisciplinary care team, collaborate with other clinical and nonclinical stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member and coordinate care.
i. Document review processes and decisions accurately, consistently and timely within the review documentation system by following the standard work guidelines and policies to support internal and external processes, including documentation of potential avoidable days/ admission when medical necessity criteria are not met. Meet both quality assurance and production metrics as established for the utilization management unit. Communicate approval and denial notifications and decisions to members and/or providers using both verbal and written communication.
j. Comply with regulatory standards, accreditation standards and internal guidelines; remains current and consistent with the standards pertinent to Care Management Team.
k. Other duties as assigned.
Requisition ID: 214642
External Company Name: Wellmark Blue Cross and Blue Shield
External Company URL: www.wellmark.com