Nurse Medical Management I (Remote)
Vacancy expired!
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-Indiana
Vacancy expired!