Vacancy expired!
Nurse Medical Mgmt I - (OH, KY, IN, TN, MO and WI or remote)Location: Ohio, United StatesNewRequisition #: PS26543Your 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 CompanyThis position supports the Central region states of Ohio, Indiana, Kentucky, Tennessee, Missouri, and Wisconsin (both Central and Eastern time zones).Hours: EST and Central standard time availability. Mon – Friday weekends only if needed;Remote is available for these areas but must be in within reasonable commuting distance from an Anthem primary office location.Responsible for collaborating 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.Primary duties may include, but are not limited to:
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.
Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products, and steers members to appropriate providers, programs or community resources.
Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment.
Conducts pre-certification, inpatient, retrospective, out of network and 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.
May participate in or lead intradepartmental teams, projects and initiatives.
Requires current- active unrestricted RN license to practice as a health professional in State of residence
Minimum of 2+ years (Level I) acute care clinical experience required or any combination of which would provide an equivalent background. .
Utilization management experience required
Prior case management and managed care experience 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, facilitation skills, and analytical skills.
Knowledge and understanding of CMS criteria, Medicare criteria, Milliman Care Guidelines, and InterQual criteria preferred.
Must have strong Microsoft Office skills.
Experience with Facets highly desired.
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 please visit us at .AnEqualOpportunityEmployer/Disability/Veteran
Vacancy expired!