Nurse Medical Mgmt I/II

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.Nurse Medical Management I/IIWork location: Remote, within 2 hour drive of any Anthem location Work schedule: M-F 8:00am to 5:00pm ESTResponsible for, review of billed services to optimize member benefits, and to promote effective use of resources; or for more complex medical issues primary duties may include, but are not limited to: Ensure medically appropriate, high quality, cost effective care through medical necessity review of claims billing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable CMS and health plan medical policy and industry standards, accurately interpreting benefits and managed care products.

Applies clinical knowledge to ensure medical necessity of billed service.

Works with medical directors in interpreting appropriateness of care and accurate payment.

Conducts inpatient and outpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

Ensure member benefits are correctly applied to claims payment.

Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care is reimbursed per the member’s contract.

May participate in or lead intradepartmental teams, projects and initiatives.

Interacts with service operations as well as other areas of the company relative to claims reviews and their status.

Analyze and trends performance data, and works with service operations to improve processes and compliance.

Assist investigators by providing medical review expertise to accomplish the detection of fraudulent activities.

Qualifications Nurse Medical Management ICurrent active unrestricted RN license to practice as a health professional within the scope of practice in applicable in state you reside in.

Current active unrestricted Nevada RN license is a plus.

2 years clinical RN experience.

Experience working with Microsoft Office (Outlook, Excel, and Word).

Experience using electronic documentation and using multiple computer screens.

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

Prior managed care experience strongly preferred.

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

Experience working in a production environment preferred.

Medicare, Medicaid &/or Medicare Supplement review experience required.

Coding experience preferred.

Experience with online medical management and/or claim systems required.

Multistate licensure is required if this individual is providing services in multiple states.

Nurse Medical Management IICurrent active unrestricted RN license to practice as a health professional within the scope of practice in applicable in state you reside in.

Current active unrestricted Nevada RN license is a plus.

3-5 years clinical RN experience.

Experience working with Microsoft Office (Outlook, Excel, and Word).

Experience using electronic documentation and using multiple computer screens.

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

Prior managed care experience strongly preferred.

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

Experience working in a production environment preferred.

Medicare, Medicaid &/or Medicare Supplement review experience required.

Coding experience preferred.

Experience with online medical management and/or claim systems required.

Multistate licensure is required if this individual is providing services in multiple states.

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: PS40339