19 Aug
Nurse Medical Mgmt I - West Des Moines, IA - PS37949
California, Picorivera 00000 Picorivera USA

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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. Nurse Medical Management I Location: West Des Moines, Iowa (this position is temporarily designated as work at home, once the office re-opens, this position will be in the office)The Nurse Medical Management 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.

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.

Key Attributes: Milliman Care Guidelines, Utilization Management, Evidence Based Criteria, Medical Necessity Review.Qualifications Requirements:

Current active unrestricted RN license in the state of Iowa to practice as a health professional within the scope of practice in Iowa.

2 years acute care clinical experience.

Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

Preferred:

Participation in the American Association of Managed Care Nurses preferred.

Prior managed care experience strongly preferred.

Key Attributes: Milliman Care Guidelines, Utilization Management, Evidence Based Criteria, Medical Necessity Review.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: PS37949

Vacancy expired!


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