Nurse Medical Management I (Remote)
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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!