Anthem Nurse Utilization Mgmt / Review (FHPS) l, ll, Sr - Prefer Denver, Indianapolis, Atlanta, or Richmond / Office-based initially (PS26724) in Long Beach, California
Nurse Utilization Mgmt / Review (FHPS) l, ll, Sr - Prefer Denver, Indianapolis, Atlanta, or Richmond / Office-based initially (PS26724)
Location: United States
Requisition #: PS26724
Post Date: Sep 05, 2019
Your 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.
We have multiple openings for the Nurse Medical Management role that may be filled as a level I, II or Senior. The level will be determined in accordance to the candidates experience in relation the requirements of the position.
Preferred Location: Any Anthem or Amerigroup office but must be able to work within the hours listed below. There may be an option offered to work from home once training is complete and certain metrics have been met consistently.
Other locations: Candidates who are only able to work from home due to proximity to an Anthem / Amerigroup office may be considered, but must be able to work within the hours listed below.
Work Hours: You may reside in any time zone but must be able to work a set, 8 hour shift, Monday through Friday, between the Eastern Time Zone hours of 8am – 7pm.
The Nurse Medical Management I, ll and Sr. are responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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 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.
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.
May also manage appeals for services denied.
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 member’s 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 Management II, i n addition to the above responsibilities, may participate in, or lead, intradepartmental teams, projects and initiatives. Nurse Medical Management Sr., i n addition to the responsibilities of the level l and ll roles, may be responsible for the following:
Serve as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues.
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, and contracts.
Nurse Medical Management I, ll, and Sr require:
2 years of acute care clinical experience (3 years for the Level ll and 3 or more years acute care clinical experience with utilization management / review or managed care experience for the Sr. Level role); or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in the state where you reside.
AS/BS in nursing preferred.
Utilization Management experience preferred.
Nurse Medical Management II, in addition to the above requirements, should have the following:
Participation 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.
Nurse Medical Management Sr. , in addition to the above requirements must exhibit the following:
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Current or former experience working within the FHPS (FEP) organization of Anthem.
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.
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