Job Details

ID #3046716
State California
City Downey
Full-time
Salary USD TBD TBD
Source Anthem, Inc.
Showed 2019-12-16
Date 2019-12-17
Deadline 2020-02-15
Category Et cetera
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Nurse Medical Mgmt I/II

California, Downey 00000 Downey USA

Vacancy expired!

Nurse Medical Mgmt I/IILocation: United StatesNewRequisition #: PS31647YourTalent. Our Vision. At Anthem, Inc., it’s a powerful

combination, and the foundation upon which we’re creating greater access to

care for our members, greater value for our customers, and greater health for

our communities. Join us and together we will drive the future ofhealth care .This

is an exceptional opportunity to do innovative work that means more to you and

those we serve at one of America's leading health benefits companies and a

Fortune Top 50 Company.NurseMedical Mgmt II or ILocation: Work

from home.Must live within 60 miles of an Anthem

location.Please note, wecurrently have one opening for this position and level will be determined bycandidates’ skills, experience and education.The Nurse MedicalManagement II associate responds to more complex medical issues, serves asresource to lower-leveled nurses, and may participate in or leadintradepartmental teams, projects and initiatives.In

this position, you are responsible to collaborate telephonically with

healthcare providers to promote quality member outcomes, to optimize member

benefits, and to promote effective use of resources.Primaryduties may include, but are not limited to:

Conductspre-certification, continued stay review, care coordination and dischargeplanning for appropriateness of treatment setting reviews to ensurecompliance with applicable criteria, medical policy, and membereligibility, benefits, and contracts.

Ensuresmember access to medically necessary quality healthcare in a costeffective setting according to member contract.

Consultswith clinical reviewers and/or medical directors to ensure medicallyappropriate, high quality, care throughout the medical management process.

Assessesthe medical necessity of outpatient services, focused surgical anddiagnostic procedures, out of network services, and appropriateness oftreatment setting.

Utilizesthe applicable medical policy and industry standards, accuratelyinterprets benefits and managed care products.

Steersmembers to appropriate providers, programs or community resources.

Collaborateswith providers to assess members' needs for early identification of andproactive discharge planning.

Facilitatesmember care transition through the healthcare continuum and referstreatment plans/plan of care to clinical reviewers as required and doesnot issue non-certifications.

Facilitatesaccreditation by knowing, understanding, correctly interpreting, andaccurately applying accrediting and regulatory requirements and standards.

Workswith medical directors in interpreting appropriateness of care andaccurate claims payment.

Mayalso manage appeals for services denied.

Current, active, unrestricted RN licensefrom the state in which he/she resides

Two plus years acute care clinicalexperience is required.

Utilization Management experience isstrongly preferred.

Managed Care and/or Medicaid experienceis preferred.

Computer proficiency in Microsoft Word,Excel, and Outlook is required, along with proficient typing skills andthe ability to use a laptop computer.

Anthem, Inc. is ranked as one of

America’s Most Admired Companies among health insurers by Fortune magazine and

is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more

about our company and apply, please visit us at careers.antheminc.com. An Equal

Opportunity Employer/Disability/Veteran.

Vacancy expired!

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