Vacancy expired!
Nurse Medical Mgmt ILocation: United StatesNewRequisition #: PS29820Your
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 at one of America's leading health benefits companies and a
Fortune Top 50 Company.Title: Nurse Medical Mgmt IWORK FROM HOMELocation: New York or New JerseyMust reside within 60miles of an Anthem officeHours: 40 hours a week , Monday-Friday
between 8:30am -5pmThe Nurse Med.Mgmt. I utilizes inpatient and outpatient utilization review skills to
evaluate the necessity, appropriateness and efficiency of the use of medical
services for LTSS (long term services and supports) and 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 long term care, outpatient services, 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 member’s needs for early identification of and proactive
planning for 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.Current Active
unrestricted RN license to practice as a health professional within the scope
of practice in the state of New YorkReside in New York or
New JerseyActive New York State
Driver’s License or State ID(For security purposesto access Health Commerce System)Experience with the
Health Commerce System2 year's case management
experience working with health insurance benefits and managed care plans.Requires strong oral,
written and interpersonal communication skills, problem-solving skills,
facilitation skills, and analytical skills.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!