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Nurse Medical Mgmt ILocation: United StatesNewRequisition #: PS30505Your 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.Nurse Medical Management ILocation: CALIFORNIAWork from homeMust live within 50 milesfrom an Anthem OfficeWork hours: M - F 8:00 am - 5 pm PSTThe Nurse Medical Management I position 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
for accurate claims payment.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 physician clinical reviewers as required to issue non-certifications of
services as appropriate.· Facilitates accreditation
by knowing, understanding, correctly interpreting, and accurately applying
accrediting and regulatory requirements and standards.· Requires current active unrestricted RN license in CA
to practice as a registered nurse within the scope of practice in CA and 2
years acute care hospital clinical experience as a registered nurse. Will
consider RNs with 1 year of recent experience and prior paramedic healthcare
experience (within last 2 years prior to RN licensure) for clinical experience.· Requires strong oral, written and interpersonal
communication skills, problem-solving skills, facilitation skills, analytical
skills, and effective time management skills.· Strong proficiency with MS Outlook, Word, and Excel,
and other related software and computer programs/platforms needed in daily
utilization management work.· Will be required to set up computer components with
remote assistance as needed.· Must be able to troubleshoot and resolve IT issues
with telephonic IT assist as needed· Must have strong critical thinking skills in clinical
and managed care areas.Anthem, Inc. isranked as one of America’s Most Admired Companies among health insurers byFortune magazine and is a 2018 Diversity Inc magazine Top 50 Company forDiversity. To learn more about our company and apply, please visit us atcareers.antheminc.com.An Equal Opportunity Employer/Disability/Veteran.
