Nurse Medical Mgmt I/II or Sr (Job Family) - REMOTE (Multiple Openings) - PS25293

Nurse Medical Mgmt I/II or Sr (Job Family) - REMOTE (Multiple Openings) - PS25293

16 Sep 2024
New Hampshire, Manchester 00000 Manchester USA

Nurse Medical Mgmt I/II or Sr (Job Family) - REMOTE (Multiple Openings) - PS25293

Vacancy expired!

Nurse Medical Mgmt I/II or Sr (Job Family) - REMOTE (Multiple Openings) - PS25293Location: United StatesNewRequisition #: PS25293Your 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.Multiple positions open for Nurse Medical Mgmt I/II or Sr.Preferred Location s: Remote but Residents in Western US are a plus!Other Locations: Remote, anywhere in the US. Must be able to work a schedule between 8am – 8pm EST but may vary for coverage purposes.Nurse Medical Management I/II/Sr. (Job Family)Please Note: This position may be filled at the Nurse Medical Management I, Nurse Medical Management II, or Nurse Medical Management Senior level. Manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.Nurse Medical Management IResponsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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. 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: Conducts pre-certification, continued stay review, care coordination, or discharge planning for 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 member’s 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.Nurse Medical Management IIResponsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. 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. 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: Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Consults 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 member’s 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.Nurse Medical Management Sr.Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. 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. 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: continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Conducts precertification, continued stay review, care coordination, or discharge planning for 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.Nurse Medical Management I:Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 2 years acute care clinical experience. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Nurse Medical Management II:Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. 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. Prior managed care experience strongly preferred. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. The following are level distinctions not required for posting. This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Nurse Medical Management Sr.Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. Certification 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. Prior managed care experience required. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Must exhibit leadership skills. The following are level distinctions not required for posting. This level serves as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, may lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical 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.

Related jobs

  • The Critical Care Registered Nurse assumes responsibilityand accountability for the application of the nursing process and the deliveryof patient care in a variety of critical care settings. Consistently performsaccording to nursing standards and is accountable in managing patient care andassisting others in the management of patient care. Responsibilities includemonitoring, assessment, vital sign monitoring, ventilator management,medication administration, intravenous insertion and infusion, central linecare, catheters, and maintenance of a running record of the patient’s status.The Critical Care RN must be prepared at all times to perform cardiopulmonaryresuscitation and other lifesaving measures for the patients in their care.

  • The Emergency Department Registered Nurse assumesresponsibility and accountability for the application of the nursing processand the delivery of patient care in the emergency room setting or other emergentcritical care areas.

  • Maxim Healthcare Staffing is seeking a Progressive Care Unit RN, as a professional practitioner, to assume the responsibility and accountability fordelivering patient care to telemetry/progressive care patients. The nurse demonstratestheability tomake clinical judgmentsin an effective andefficient manner with supervision. Thisindividual employs critical thinking andperformance ability in the coordinator of patient care, consistentlyperforms according to nursing standards, andis accountable in managing patient care andassisting others in themanagement of patient care.

  • WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Elevance Health requires a completed online application for consideration of employment for any position. We will never ask you for a credit card, send you a check, or ask you for payment as part of consideration for employment.

  • WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Elevance Health requires a completed online application for consideration of employment for any position. We will never ask you for a credit card, send you a check, or ask you for payment as part of consideration for employment.

  • As a District Service Manager, you will lead and manage a team of Field Service Engineers for the Western New England district for Imaging Systems customer services, participating in the development and implementation of strategic and tactical plans to achieve annual revenue targets from core business and value-added services. Your team will be responsible for customer satisfaction, performing to maintain and enhance the image of Philips in the local marketplace.

  • REGISTERED NURSE -RN - School Nursing

Job Details

Jocancy Online Job Portal by jobSearchi.