Nurse Medical Management I (Remote)

Nurse Medical Management I (Remote)

05 Jun 2024
Virginia, Virginiabeach 00000 Virginiabeach USA

Nurse Medical Management I (Remote)

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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 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.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, 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.

Qualifications Requirements

Requires current active unrestricted RN license

to practice as a health professional within the scope of practice in the State

of Indiana and 2 years acute care clinical experience.

Utilization Management experience highly

preferred.

Medicaid experience preferred.

Requires strong oral, written and interpersonal

communication skills, problem-solving skills, facilitation skills, and

analytical skills.

Position is work from home, however, must live

within commutable distance to an Anthem office in the State of Indiana.

Must be able to work 8am-5pm Eastern Standard

Time schedule, Monday-Friday.

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: PS36108

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