At WellCare, we are a passionate team with a strong mission and a focused purpose: to serve our members and local communities in which they live while helping them lead better, healthier lives. Our culture is one of empowerment, teamwork and commitment as we all work together to deliver cost-effective solutions that create positive outcomes for our members. Join us in a career that inspires passion and purpose across all levels and disciplines within our award-winning organization.
Utilizes care coordination tools, criteria and protocols to provide care coordination to lower acuity members with acute and chronic health care needs. Provides education and support in assisting members to achieve optimal level of wellness. Works with member to support compliance with care and treatment plans in collaboration with the interdisciplinary care team.
- REQUIRED: 4 years of experience with the pediatric population
Reports to: Supervisor of Field Care Management
Department: Children's Medical Services
Location: Palm Beach County, Florida
- Perform member interviews to assist with gathering of information
- Perform follow up with members engaged in case management
- Facilitate provider contact as needed to coordinate member's care needs. Initiates appropriate referrals and inputs authorizations as needed for members active in case management.
- Support the identification of high-risk members for disease or case management needs and works with member, physician and other Health care providers to meet the member's individual needs.
- Identifies and escalates member cases with complex medical needs to Supervisor or Manager.
- Act as liaison and member advocate between the member/family, physician and facilities/agencies.
- Coordinates community resources, with emphasis on medical, behavioral, and social services. Applies case management standards, maintains HIPAA standards and confidentiality of protected health information and reports critical incidents and information regarding quality of care issues.
- Instructs the member on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, facilitate physician visits.
- Documents all contacts in the Health Services clinical documentation system.
- Manage members in disease management program, completing and revising as necessary, the information in clinical documentation system.
- Ensures compliance with all state and federal regulations as well as Corporate guidelines in day-to-day activities.
- Meets with clients in their homes, work-sites, physician’s or hospital to provide management of services.
- Adapts to changes in policies, procedures, new techniques and additional responsibilities.
- Participates with other Case Managers and Medical Directors in regular or special meetings such as Clinical rounds.
- Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and Corporate and department policies and procedures.
- Identifies potential quality of care issues and appropriately refers to the quality department.
- Assists in the implementation of specific strategies that improve the quality and outcomes of care.
- Educates members and facilitates HEDIS gap closure.
- Performs all other duties assigned.
- Works under direct supervision of a Registered Nurse
- Travel to inpatient bedside, member’s home, provider’s office, hospitals, etc required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards. May require climbing multiple flights of stairs to a member's home, provider's office, etc.
- Required A High School or GED
- Preferred An Associate's Degree in nursing
- Required 2 years of experience in utilization management and/or case management in a hospital or home health setting or with a managed care organization.
- Preferred Other prior experience working with a geriatric population
- Required Other In the Florida market, 4 years in pediatric experience
- Required Other Work experience requirements may be waived for associates engaged in Florida's CMS contract that worked in a similar capacity for Florida's Department of Health in 2018.
- Intermediate Ability to drive multiple projects
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to work independently
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Other Ability to provide input to care/treatment plan
- Intermediate Demonstrated negotiation skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to implement process improvements
A license in one of the following is required:
- Required Other Current unrestricted LPN/LVN state license
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.