Description
SHIFT: Day Job
SCHEDULE: Full-time
Your 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
Title: Nurse Med Management I - Utilization Review
Location: Work from home- must live within 40 miles of an Anthem office
Status: Full-time, 40 hours a week
Monday through Friday
8am to 5pm EST
There might be a need to work on a Saturday, depending on workload demands
The Nurse Med Management I is responsible to collaborate with healthcare providers 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.
• Communication with providers/care coordinators/case managers will be done via telephone as well as email.
Qualifications
• Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States (Compact State RN License is ideal or must at least have RN license for New Hampshire)
• 2-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
• Must have some knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Prior managed care experience strongly preferred.
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com.
An Equal Opportunity Employer/Disability/Veteran.
Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
REQNUMBER: PS42400