RN Nurse Medical Management I

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 healthcare.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.LOCATION: This is a remote position servicing our Kentucky Medicaid members. You must live within 60 miles of an Anthem office, and you must hold an active Kentucky RN license.HOURS: 8:00a - 5:00p, 9:00a - 6:00p, or 10:00a - 7:00p (all times EST), Monday through Friday. Must be agreeable to weekend/holiday rotation, 8:00a - 5:00 pm.Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and to promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs or community resources. 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, high 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.

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

May also manage appeals for services denied.

Qualifications Current unrestricted RN license from the state of Kentucky is required.

3 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background, is required.

Knowledge of medical management process, and ability to interpret and apply member contracts, member benefits, and managed care products, is required.

Utilization Review experience, with Inpatient discharge planning, and Outpatient services, such as therapies, DME, and home health, is preferred.

Prior Medicaid and/or managed care experience is preferred.

You must be agreeable to providing weekend/holiday coverage hours on a rotating basis.

You must be competent in Microsoft Word, Excel and Outlook.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 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: PS41337-Ohio