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Nurse Medical Mgmt I or Nurse Medical Mgmt IILocation: United StatesNewRequisition #: PS27117Nurse Medical Mgmt I is responsible 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 Mgmt II is responsible 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 Mgmt 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 Mgmt 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.
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.
