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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 Management I/II (Medical Groups Liaison) Location: Remote in CA (Must be located 1 hour for an Anthem location)Work schedule: M-F normal business hoursResponsible to collaborate with delegated Medical Groups and Providers to promote quality member outcomes and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, 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:Correspond/interface with delegated Medical Groups on clinical areas primarily related to utilization management, case management.
Collaborate with Delegation Oversight to conduct focus audit of inpatient cases on medical groups that have inpatient delegation to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Attends weekly inpatient rounds with medical groups that have inpatient delegation to assess members’ needs for early identification of and proactive planning for discharge planning.
Share available UM tools to delegated medical groups to facilitate concurrent management.
Knowledge of Medicaid accreditation and regulatory requirements.
Support the monitoring/tracking of the UM key performance indicators for medical groups that enrolled in the incentive program.
10% traveling for meetingsactivities as needed (post COVID)
Qualifications Requires current active unrestricted RN license from the State of CA.
At least 2-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
Prior Medicaid, managed care experience strongly preferred.
Must have knowledge of UM/CM medical management processes and ability to interpret and apply member contracts, member benefits and UM key performance indicators.
Prior concurrent review and/or audit experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Microsoft office products knowledge required.
Project and program management experience preferred.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.REQNUMBER: PS42470
