Nurse Medical Mgmt I - Remote (Near an Anthem office) PS5191

Nurse Medical Mgmt I - Remote (Near an Anthem office) PS5191
Location: United States
Field: Medical
Requisition #: PS5191
Post Date: Apr 24, 2018
Your 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.
The Nurse Medical Management 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 members 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.
+ Requires current active unrestricted RN license to preactice as a health professional within the scope of pracice 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.
_This position has zone restrictions. The Hiring Manager is not considering candidates that reside in California or New York (Zones 1 or 2)._
_Work at home is available, but must reside within 2 hours of an Anthem office._
Anthem, Inc. is ranked as one of America?s Most Admired
Companies among health insurers by Fortune magazine and is a 2017 DiversityInc
magazine Top 50 Company for Diversity. To learn more about our company and
apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.

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