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Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 care companies and a Fortune Top 50 Company.Nurse Medical Manager I, II, Sr (Job Family)Please note: this position may be filled at either the Nurse Medical Manager I, II or Sr. level. The hiring manager will determine level, based on the candidate’s experience and background.Responsible to serves 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. 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: 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. Conducts precertification, 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. Ensures consistency in benefit application. Qualifications The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.Nurse Medical Manager I Minimum Requirements: 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 minimum of 2 years acute care clinical experience. Preferred Qualifications: Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.Nurse Medical Manager II Minimum Requirements: 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. Requires minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background. Prior managed care experience required. Preferred Qualifications: Certification in the American Association of Managed Care Nurses preferred. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred. Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred. Leadership skills strongly preferred. Nurse Medical Manager Sr. Minimum Requirements 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. Requires minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background. Prior managed care experience required.Preferred Qualifications: Certification in the American Association of Managed Care Nurses preferred. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred. Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred. Leadership skills strongly preferred.We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions. REQNUMBER: PS64146-California
