Vacancy expired!
RN / Nurse Medical Management II - Maryland or open to remote arrangement PS27305Location: Maryland, United StatesNewRequisition #: PS27305Your Talent. 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 of health care .This is an exceptional opportunity to do innovative work that means more to you and those we serve atone of America's leading health benefits companies and a Fortune Top 50 Company.RN/Nurse Medical Management IIWork location: Baltimore, Maryland area is preferred; this position allows for working remotely / prefers a remote arrangement in MarylandThis position is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, andappropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.Primary duties may include, but are not limited to:
Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Requires current active unrestricted RN license to practice as a health professional in the state of Maryland.
3-5 years of Utilization Management experience.
NICU experience strongly preferred.
Medical record review experience very strongly preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, memberbenefits, and managed care products.
Prior managed care experience strongly preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, andanalytical skill.
Anthem, Inc. is ranked as one of America’sMost Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityIncmagazine Top 50 Company for Diversity. To learn more about our company andapply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.
Vacancy expired!