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Mgr II Medical Mgmt (Medicare) - REMOTE (NY, NJ, CT, NH, ME, VA, GA or FL)Location: New York, United StatesNewRequisition #: PS27753Your 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.Manager II - Medical Management - REMOTELocation: can be located in any of the following states: NY, NJ, CT, NH, ME, VA, GA, or FLThe Medical Management Manager II oversees Medicare CM programs including Medicare Advantage, Fully Integrated Duals Advantage (FIDE) and Dual Eligible Special Needs Plans (D-SNP). The Medical Management II Manager is responsible for ensuring appropriate Care Management operations by overseeing a team consisting of Care Managers, Social Workers and/or Care Coordinators. This role also includes collaborating and communicating with various departments to ensure appropriateness in delivery of care, accuracy in data, quality improvement, and to deliver optimal quality of care to members.Primary responsibilities:
Plan, manage and lead all Case Management activities of the Medicare and DSNP programs.
Monitor, develop, and recommend changes in operational procedures, including workflows, policies and procedures that promote quality person-centered care for members, monitor productivity and risk management, cost-effectiveness, staff engagement, performance, and satisfaction
Collaborate with Quality Management and Care Management to implement effective methods to optimize access to preventive care screenings and disease management for members.
Participates in audits conducted by Anthem or external parties, such as State level audits, Centers for Medicaid and Medicare audits, and/or accreditation activities.
Participate and lead clinical rounds or case conferences as needed and provide clinical solutions that may include but not limited to: access to care for members, discharge planning, member education, coordination of care.
Actively work with Utilization Management Department to ensure that the member has a needs-based level of services are available and delivered in a timely, cost-effective manner based upon any relevant change in member’s condition
Work with senior management and leadership to develop models of care, identify issues and develop solutions for the Medicaid-Medicare and Medicare programs. Experience managing C-SNP (Chronic condition SNPs) programs preferable.
Assure Complex Care Department’s activities remain compliant with all regulatory, contractual, and internal standards and requirements.
Collaborates with CM vendors to ensure proper care coordination is in place between internal and external CM stakeholders
Requires 5 years of acute care clinical experience; 2 years or prior management experience; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
BS preferred.
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.
