Vacancy expired!
Nurse Medical Mgmt ILocation: United StatesNewRequisition #: PS31489Your 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 .Nurse Medical ManagementILocation: Workfrom Home positionRESPONSIBILITIES:Responsible to
collaborate 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, 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.Conducts review for
appropriateness of treatment setting to ensure compliance with applicable
criteria, medical policy, and member eligibility, benefits, and contractsconsults with clinical
reviewers and/or medical directors to ensure medically appropriate, high
quality, cost effective care throughout the medical management process.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 applicable
state(s) or territory of the United States.3-5 years acute care
clinical experience or case management, utilization management or managed care
experience, which would provide an equivalent background.Must have knowledge of
medical management process and ability to interpret and apply member contracts,
member benefits.Prior managed care
experience strongly preferred.Requires strong oral,
written and interpersonal communication skills, problem-solving skills,
facilitation skills, and analytical skills.An Equal Opportunity Employer/Disability/Veteran
Vacancy expired!