Nurse Medical Mgmt l or ll - Post Svc Clinical Claims Review - East Coast - Remote (PS26709)

Nurse Medical Mgmt l or ll - Post Svc Clinical Claims Review - East Coast - Remote (PS26709)

24 Aug 2024
Georgia, Savannah / hinesville 00000 Savannah / hinesville USA

Nurse Medical Mgmt l or ll - Post Svc Clinical Claims Review - East Coast - Remote (PS26709)

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Nurse Medical Mgmt l or ll - Post Svc Clinical Claims Review - East Coast - Remote (PS26709)Location: Tampa, Florida, United StatesNewRequisition #: PS26709Your 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.Location: Remote, East Coast Business Hours requiredNote : This position may be filled at either the l or ll level and will depend upon the skills and experience of the candidate selected.The Nurse Medical Mgmt I / ll is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources; or for more complex medical issues 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 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.

Requires:

AS/BS in nursing; 2+ years (Level l) and 3-5 years (Level ll) acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

Current unrestricted RN license required in the state in which you reside.

Minimum 1 year experience with Medical review / record review is required.

Post Service Clinical Claims Review (PSCCR) experience is preferred.

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.

Utilization Management experience is required.

Prior Managed Care/Medicaid experience preferred.

Must have excellent PC skills (Word, Excel), Facets

Medical coding experience and familiarity with CPT, ICD-9, ICD-10 codes is a plus

Experience with Milliman or Interqual is preferred.

Must have strong clinical skills, i.e. med/surg

Must have excellent communication skills (written and verbal), interpersonal skills, and organizational skills.

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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