21 Aug
Nurse Medical Management I (Remote)
California, Applevalley 00000 Applevalley USA

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.Preferred Location: New

YorkThe 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 medicallyappropriate, 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 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.

If hired, you will be

required to obtain an unrestricted RN license for the state of New York.Qualifications Requirements

Requires current active

unrestricted RN license to practice as a health professional within the

scope of practice in New York. If you are not licensed in the State

of New York, you are required to obtain a New York RN license after hire.

At least 2 years acute care

clinical experience.

Requires strong oral, written

and interpersonal communication skills, problem-solving skills,

facilitation skills, and analytical skills.

Must be able to work East Coast

Hours.

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: PS36980

Vacancy expired!


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