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Nurse Medical Mgmt I/II PS29587

Anthem Reston, VA
  • Expired: November 03, 2019. Applications are no longer accepted.

Nurse Medical Mgmt I/II PS29587
Location: United States
New
Requisition #: PS29587
Post Date: 4 hours ago
Our Talent. Our Vision. At Anthem, Inc., it's a powerful combination, and the foundation
upon which we're creating greater 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 Mgmt I/II
Location: Remote - Must reside in CA
Please note, we currently have one openingfor this position and level will be determined by candidates' skills,experience and education.
The NurseMedical Mgmt I/II is responsible to collaborate with healthcare
providers to promote quality member outcomes, to optimize member benefits, and
to promote effective use of resources. 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 pre-certification,continued stay review, care coordination, or discharge planning forappropriateness of treatment setting reviews to ensure compliance withapplicable criteria, medical policy, and member eligibility, benefits, andcontracts.
  • Ensures member access tomedical necessary, quality healthcare in a cost effective settingaccording to contract.
  • Consult with clinical reviewersand/or medical directors to ensure medically appropriate, high quality,cost effective care throughout the medical management process.
  • Collaborates with providers toassess members' needs for early identification of and proactive planningfor discharge planning.
  • Facilitates member caretransition through the healthcare continuum and refers treatmentplans/plan of care to clinical reviewers as required and does not issuenon-certifications.
  • Facilitates accreditation byknowing, understanding, correctly interpreting, and accurately applyingaccrediting and regulatory requirements and standards.
Nurse Medical Mgmt I:
  • Requires current activeunrestricted RN license to practice in the State of California
  • Requires 2 years acute careclinical experience.
  • Bachelors of Science in Nursing degree preferred
  • Requires strong oral, writtenand interpersonal communication skills, problem-solving skills,facilitation skills, and analytical skills.
  • Previous case management and/or utilization management preferred
Nurse Medical Mgmt II:
  • Requires current activeunrestricted RN license to practice in the State of California
  • Requires 3-5 years acute careclinical experience or case management, utilization management or managedcare experience, which would provide an equivalent background.
  • Bachelors of Science in Nursing degree preferred
  • Must have knowledge of medicalmanagement process and ability to interpret and apply member contracts,member benefits, and managed care products.
  • Prior managed care experiencestrongly preferred.
  • Requires strong oral, writtenand interpersonal communication skills, problem-solving skills,facilitation skills, and analytical skills.
Anthem, Inc. is ranked as one ofAmerica's Most Admired Companies among health insurers by Fortune magazine andis a 2018 Diversity Inc magazine Top 50 Company for Diversity. To learn moreabout our company and apply, please visit us at careers.antheminc.com.
An EqualOpportunity Employer/Disability/Veteran.

Anthem

Address

Reston, VA
20190 USA