Nurse Case Mgr I/II/Sr
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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. 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.Work From HomeNurse Case Manager IThe Nurse Case Manager I is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planningPrimary duties may include, but are not limited to:
Ensures member access to services appropriate to their health needs.
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims or service issues.
Experience with Case Management and Utilization Management a plus.
Nurse Case Manager IIThe Nurse Case Manager II is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning.Primary duties may include, but are not limited to:
Ensures member access to services appropriate to their health needs.
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures.
Experience with Case Management and Utilization Management a plus.
Nurse Case Manager SeniorThe Nurse Case Manager Senior is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning.Primary duties may include, but are not limited to:
Ensures member access to services appropriate to their health needs.
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
Participates in department audit activities.
Experience with Case Management and Utilization Management a plus.
Qualifications Nurse Case Manager I
Requires a BA/BS in a health related field; 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license required in Georgia, Indiana or Virginia is required.
Certification as a Case Manager is preferred.
UM experience a plus.
Nurse Case Manager II
Requires a BA/BS in a health related field; 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license required in Georgia, Indiana or Virginia is required.
Certification as a Case Manager is preferred.
Nurse Case Manager Senior
Requires a BA/BS in a health related field; 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license required in Georgia, Indiana or Virginia is required.
Certification as a Case Manager is preferred.
Specific Qualifications
Utilization Management and Skilled Nursing Facility (SNF) experience is preferred.
Acute Clinical care experience is highly desired.
Qcare experience
Health insurance experience- highly preferred
Familiarity ACMP and Tri-Med preferred.
Excellent oral and written communication skills; strong analytical and problem solving abilities; attention to detail, excellent follow through and strong organizational skills.
Multi-state license requires.
UM experience a plus.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.REQNUMBER: PS37054
Vacancy expired!