[Close] 

RN Nurse Medical Mgmt. I or II (Utilization Management) Remote - US - PS4979

RN Nurse Medical Mgmt. I or II (Utilization Management) Remote - US - PS4979
New
Location: United States
Field: Medical
Requisition #: PS4979
Post Date: Apr 20, 2018
Your 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.
The Nurse Med. Mgmt. I or II will focus on Utilization Management. There are three new positions supporting the expansion of the Group Retirement Solutions program. You will be given the training and equipment to work from a home office. You must have a high speed internet connection in your home.
The Nurse Med Mgmt. 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 for more complex medical issues. Ensures medically appropriate, 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 precertification, 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.
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.
These positions may be hired as a Nurse MM I or II depending upon the skills, background and experience of the chosen candidates.
Requires a current, active, unrestricted RN license to practice as a health profesional in the state in which you reside, and a minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
-Participation in the American Association of Managed Care Nurses preferred.
-Must have knowledge of medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products.
-Managed care/Medicare experience strongly preferred.
-Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
-Computer skills: MS Office (Word, Outlook, Excel)
-Knowledge of Anthem application software a plus: Facets, Care Compass.
You must be comfortable using a laptop and web-based applications. Lack of computer skills could hamper your ability to be successful in this position.
Anthem, Inc. is ranked as one of America?s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.


Don't Be Fooled

The fraudster will send a check to the victim who has accepted a job. The check can be for multiple reasons such as signing bonus, supplies, etc. The victim will be instructed to deposit the check and use the money for any of these reasons and then instructed to send the remaining funds to the fraudster. The check will bounce and the victim is left responsible.