Job Details

ID #4517795
Estado Carolina del Norte
Ciudad Cary
Full-time
Salario USD TBD TBD
Fuente Anthem, Inc.
Showed 2020-08-05
Fecha 2020-08-06
Fecha tope 2020-10-05
Categoría Etcétera
Crear un currículum vítae

Nurse Medical Management I/II

Carolina del Norte, Cary 00000 Cary USA

Vacancy caducado!

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 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 Management I/IIResponsible

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 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.

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 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.

The following are level

distinctions not required for posting.

This level responds to more

complex medical issues, serves as resource to lower-leveled nurses, and

may participate in or lead intradepartmental teams, projects and

initiatives.

Qualifications Requirements

Requires current active

unrestricted RN license to practice as a health professional in applicable

state(s) or territory of the United States and 3-5 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

process and ability to interpret and apply member contracts, member benefits,

and managed care products.

Prior managed care experience strongly

preferred.

Requires strong oral, written and interpersonal

communication skills, problem-solving skills, facilitation skills, and

analytical skills.

Level II responds to more complex medical

issues, serves as resource to lower-leveled nurses, and may participate in or

lead intradepartmental teams, projects and initiatives.

Position is remote; Must live within commutable distance to an Anthem office for occasional meetings, trainings, etc.

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.REQNUMBER: PS37792

Vacancy caducado!

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