Vacancy caducado!
Description SHIFT: Day JobSCHEDULE: Full-timeYour
Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc.
family of companies focused on serving Medicaid, Medicare and uninsured individuals,
it’s a powerful combination.
It’s 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. Nurse Medical Management I – NICU UMResponsible 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 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.
Ensures member access to medical necessary,
quality healthcare in a cost effective setting according to contract.
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 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.
Qualifications RequirementsCurrent, unrestricted RN license in the State of Nebraska OR Compact
RN License required and 2 years acute care
clinical experience.
Requires strong oral, written and interpersonal
communication skills, problem-solving skills, facilitation skills, and
analytical skills.
UM experience required.
NICU nursing background
required.
MCG experience nice to have.
Microsoft Office Suite proficiency required.
Schedule is
Monday-Friday, 8am-5pm CST.
Anthem, Inc. is ranked as one of America’s Most Admired
Companies among health insurers by Fortune magazine and is a 2018 DiversityInc
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: PS40333
Vacancy caducado!