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Nurse Medical Mgmt I/II - (PSCCR) - Any Anthem Office or Remote - PS26360Location: United StatesNewRequisition #: PS26360Your 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.Nurse Medical Management I or IILocation: Remote(Must live within 60 miles or 1 hour of Anthem office)Shift: Core business hours range from 6 am - 6 pmHourly positionPlease note: This position may be filled at either the Nurse Medical Management I or II level. Manager will determine level based upon the selected applicant's skillset relative to the qualifications listed for this position.The Nurse Medical Management I or II ensures medically appropriate, high quality, cost effective care through assessing the retrospective medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products in effect for the claim date of service being reviewed. Works with medical directors in interpreting appropriateness of care. Primary duties may include, but are not limited to:
Conducts retrospective precertification, continued stay review 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.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Able to thoroughly research medical record images and claims history information to support medical necessity review of services.
Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 2 years acute care clinical experience.
Case management and utilization management preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
Prior managed care experience strongly preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills and analytical skills.
ACMP experience required.
ECC/WMDS, NASCO or WGS experience a plus.
Prior PSCCR review skills and/or CPC certifications are a plus.
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 antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran
