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Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 usand 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 Mgmt I Location: This is a remote opportunity after completing up to 90 days of in-office training. Must be able to complete this training at one of the following Anthem locations: DFW, Lubbock, Houston or El Paso.Hours: Monday - Friday 8 am to 5 pm central timeTexas residency required. In this position, you are responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.Primary duties may include, but are not limited to:
Conducts pre-certification, 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.
Ensures member access to medically necessary quality healthcare in a cost effective setting according to member
contract.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, care throughout
the medical management process.
Assesses the medical necessity of outpatient services, focused surgical and diagnostic procedures, out of network
services, and appropriateness of treatment setting.
Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products.
Steers members to appropriate providers, programs or community resources.
Collaborates with providers to assess members' needs for early identification of and proactive 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.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Qualifications
Requires current, active, unrestricted RN license from the state of Texas.
Minimum of 2 years acute care clinical experience is required.
Utilization Management experience is strongly preferred.
Managed Care and/or Medicaid experience is preferred.
NICU/PEDs experience preferred
Knowledge of Facets a plus.
Computer proficiency in Microsoft Word, Excel, and Outlook is required, along with proficient typing skills and the ability to use a laptop computer.
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.REQNUMBER: PS35784-TX09
