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Transplant/Bariatric Nurse I PS26160Location: United StatesNewRequisition #: PS26160Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater 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.Transplant Nurse ILocation: Remote/Work At HomeHours: Mon - Fri 8:30am - 5:00pm (EST)The Transplant Nurse provides utilization/medical management and case management services for members receiving transplant services. The Level I Transplant Nurse focuses on utilization management responsibilities while preparing to advance to Level II which focuses on case management responsibilities.Medical management responsibilities include:
Collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for medical transplant issues.
Conduct precertifications/predeterminations.
Ensure 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.
Consults with clinical reviewers to ensure member access to medically necessary, quality healthcare in a cost effective setting according to contract.
Case management responsibilities will, within the scope of licensure, include:
Assess, develop, implement coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their specific health needs.
Conducts assessments to identify individual needs and prepares specific care management plans to address objectives and goals as identified during assessments.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Both roles facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Transplant Nurse I
Requires an AS in nursing, BSN preferred; 2 years of clinical experience preferably 3+ years of pertinent clinical experience in transplant or oncology, and/or case management or utilization management experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s).
Certification in Case Management preferred.
Strong written, oral and interpersonal communication skills.
Ability to comprehend medical policy and criteria to clearly articulate health information.
Broad clinical knowledge base of disease processes.
Ability to interpret and analyze medical information.
Knowledge of case management assessment techniques and health care service providers, community organizations and state agencies.
An understanding of appropriate member contracts and awareness of contract benefits.
Excellent people skills sufficient to establish relationships with members, families, providers, etc.
Strong customer service orientation.
Ability to multi-task.
Requires organizational, problem solving and decision-making skills.
Strong knowledge of PCs and related applications such as Excel, Word, Access, etc.
As business needs may require, this position may require additional state licenses either now or in the future. Inability or unwillingness to obtain these required licenses may result in either re-assignment (if available) or termination. Obtaining required licenses is a requirement for continued employment.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.
