Job Details

ID #2365251
State California
City Lawndale
Full-time
Salary USD TBD TBD
Source Anthem, Inc
Showed 2019-05-28
Date 2019-05-29
Deadline 2019-07-28
Category Et cetera
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Nurse Medical Management II - Remote - PS20595

California, Lawndale 00000 Lawndale USA

Vacancy expired!

Nurse Medical Management II - Remote - PS20595Location: United StatesNewRequisition #: PS20595Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. Join us andtogether we will drive the future of health care.Nurse Medical Management IILocation: Remote in any stateShift: Tuesday-Saturday (This position will be supporting West Coast business hours of 8am - 5pm PST; if you reside in Central time zone, the hours are 10am-7pm; East Coast hours would be 11am-8pm)Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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, and appropriateness 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 pre-certification, 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.

Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.

Consult 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 members 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 (within the state in which you reside).

2 years acute care clinical experience.

Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Must have at least 2 years of managed care experience preforming utilization reviews.

Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills.

Must have strong negotiation skills and ability to handle complex issues.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 Diversity Inc 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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