Vacancy expired!
Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 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 at
one of America's leading health benefits companies and a Fortune Top 50
Company.Nurse Medical Mgmt I/II/Sr - PS35985Location - California - Must reside within 1 hour of an Anthem, Inc. office locationHours - 8:00AM until 5:00PM PSTThe Nurse
Medical Management I/II/Sr is 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 and discharge
planning for appropriateness of treatment setting reviews to ensure compliance
with applicable criteria, medical policy, and member eligibility, benefits,
contracts, and Federal and State mandates.· Ensures member access
to medically necessary quality healthcare in a cost effective setting according
to member contract.· 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 members' needs for early identification of and proactive
discharge planning. Facilitates member care transition through the
healthcare continuum, 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.Qualifications Nurse Medical Mgmt. I:
Requires
current active unrestricted RN license to practice as a health professional
within the scope of practice in the state of California.
Requires
at least 2 years’ acute care clinical experience.
Electronic
Medical Records (EMR) experience. Proficient in utilizing electronic medical
records preferred.
Requires
strong oral, independent learner written and interpersonal communication
skills, problem-solving skills, and facilitation skills, analytical and
critical thinking skills.
Utilization
Management experience preferred.
Prior
Managed Care experience preferred.
Bachelor
of Science in Nursing Degree preferred
Nurse
Medical Mgmt. II/Sr:
Requires current active unrestricted RN license to practice
as a health professional in the state of California.
Requires at least 3-5 years acute care clinical experience.
Electronic Medical Records (EMR) experience. Proficient in
utilizing electronic medical records preferred.
Must have knowledge of medical management process and
ability to interpret and apply member contracts, member benefits, and managed
care products.
Requires strong oral, written and interpersonal
communication skills, problem-solving skills, independent learner and
facilitation skills, analytical and critical thinking skills.
Utilization Management experience preferred.
Prior Managed Care experience strongly preferred.
Bachelor of Science in Nursing degree
preferred.
This level responds to more complex medical issues, serves
as resource to lower-leveled nurses, and may participate in or lead
intradepartmental teams, projects and initiatives.
Prior leadership experience is a plus (not required).
This role can be filled at level I/II/Sr depending on experience/manager discretion.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.REQNUMBER: PS35985
Vacancy expired!