Nurse Medical Mgmt I/II - VA or VA Remote PS31046
Location: Virginia, United States
Requisition #: PS31046
Post Date: 6 hours ago
Your 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 .
Nurse Medical Mgmt I or II
Location: Virginia or Virginia Remote
Please note: This position may be filled at either the Nurse Medical Management I or II level. Manager will determine level
based upon the selected applicant's skillset relative to the qualifications listed for this position.
The Nurse Medical Mgmt I or II is responsible for collaborating with healthcare providers and members to promote quality
member outcomes, to optimize member benefits, and to promote effective use of resources.
Primary duties may include, but are not limited to:
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity ofinpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, andappropriateness of treatment setting by utilizing the applicable medical policy and industry standards
- Accuratelyinterprets benefits and managed care products, and steers members to appropriate providers, programs or communityresources.
- Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
- Consults 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 member's needs for early identification of and proactive planning for dischargeplanning.
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinicalreviewers as required and does not issue non-certifications.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and
- Requires current active unrestricted RN license to practice as a health professional in Virginia and at least 2 or moreyears acute care clinical experience or case management, utilization management or managed care experience, whichwould provide an equivalent background.
- Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and
- Prior managed care experience strongly preferred.
- Requires strong oral, written and interpersonal communication skills
- This level response to more complex medical issues, services a resource to lower-leveled nurses and may participate inor lead intra-department teams, projects and initiatives
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2018 Diversity Inc 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.