Vacancy expired!
Nurse Medical Mgmt II/Sr - PS30089Location: United StatesNewRequisition #: PS30089Your 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 Management II/Sr.Location: Must reside within 1 hour of an Anthem, Inc locationHours: Monday through Friday (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)Some Saturdays may be requiredResponsible 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.
Nurse Medical Mgmt II:
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.
Nurse Medical Mgmt Sr:
Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
Certification in the American Association of Managed Care Nurses preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. Prior managed care experience required.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
-Must exhibit leadership skills.Please note: Position may be filled at either a level II or Sr depending on experience/manager discretionAnthem, 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!