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Nurse Medical Mgmt Sr / II / I - (Job Family) - PS 26548 (Tri-State preferred or East Coast r...

Anthem Reston, VA
  • Expired: August 28, 2019. Applications are no longer accepted.

Nurse Medical Mgmt Sr / II / I - (Job Family) - PS 26548 (Tri-State preferred or East Coast remote)
Location: New York, United States
New
Requisition #: PS26548
Post Date: 7 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 .
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.
Tri-State location preferred but will consider other East Coast locations.
***Position may be a Nurse Medical Management I, II, or Sr depending upon level of incumbent's education and relevant skills/experience.***
Responsible to collaborate with healthcare providers and members 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 admission, continued stay review and initial skilled nursing facility and inpatient rehab admission review. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care
Primary duties may include, but are
not limited to:
Conducts pre-certification, inpatient, retrospective,
out of network and 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, qualityhealthcare in a cost effective setting according to contract.
  • Consult with clinical reviewers and/or medicaldirectors to ensure medically appropriate, high quality, cost effectivecare throughout the medical management process.
  • Collaborates with providers to assess members needs forearly identification of and proactive planning for discharge planning.
  • Facilitates member care transition through thehealthcare continuum and refers to medical director as required
  • Correctly interprets and applies appropriate regulatoryrequirements and standards
.
  • Requires an AS/BS in nursing; 2years of acute care clinical experience (3 years and 5 years respectively forhigher level); or any combination of education and experience, which wouldprovide an equivalent background.
  • Requires current active unrestrictedRN license to practice as a health professional within the scope of practice inapplicable state(s) or territory of the United States and 2 years acute careclinical experience.
  • Requires strong oral, written andinterpersonal communication skills, problem-solving skills, facilitationskills, and analytical skills.
  • Must have current or previousutilization management experience.
  • Experience with DSNP and orMedicaid/MLTSS benefits a plus.
  • Discharge planning, skilled nursingfacility (SNF) and/or rehabilitation experience strongly preferred.
  • Recent experience in GBD Facets preferred.
  • Knowledge of MCG, Inpatient Surgical(ISC) and General Recovery Guidelines (GRG) strongly preferred. Knowledgeof Medicare Benefit Policy as it applies to SNF and inpatient rehabilitationstrongly preferred.
  • Requires strong oral, written andinterpersonal communication skills, problem-solving skills, facilitationskills, and analytical skills.
Anthem, Inc. is ranked as one of America's Most AdmiredCompanies among health insurers by Fortune magazine and is a 2017 DiversityIncmagazine Top 50 Company for Diversity. To learn more about our company andapply, please visit us at . EOE. M/F/Disability/Veteran.

Anthem

Address

Reston, VA
20190 USA