Anthem RN Nurse Medical Mgmt II - Remote, US - PS14550 in Bristol, Virginia

RN Nurse Medical Mgmt II - Remote, US - PS14550


Location: United States

Field: Medical

Requisition #: PS14550

Post Date: 6 days ago

Your 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 atone of America's leading health benefits companies and a Fortune Top 50 Company.

This position supports our members who are part of Anthem's Medicare Group Retirement Solutions program. You must have a current RN license in the state in which you live . You will be given the training and equipment to work from a home office, performing duties telephonically. You must have a high speed internet connection.

Hours: This is a 40 hour work week with an agreed upon set schedule between the hours of 8:00AM - 8:00PM, that will likely include some evening and weekend hours.

The Nurse Medical Management II is responsible 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.

  • 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 members 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.

  • Requires a current, unrestricted RN license in the state in which you live.

  • BS Preferred

-Must have knowledge of medical management processes with the ability to interpret and apply member contracts, member benefits, and managed care products.

-Managed care experience strongly preferred.

-Minimum of 3 years of acute care clinical experienceor case management, utilization management or managed care experience, which would provide an equivalent background.

  • Participation in the American Association of Managed Care Nurses preferred.

  • Computer skills: MS Office (Word, Outlook, Excel)

  • Knowledge of Anthem applications a plus: Facets, Care Compass

  • You must be comfortable working on a computer. You will be working with multiple web-based applications, updating and documenting member data on excel spreadsheets, and looking up information on multiple screens simultaneously. Lack of computer skills could hinder your ability to be successful in this position.

  • You must have excellent written and verbal communication skills.

  • You must be self-motivated, professional, organized, with attention to detail.

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 An Equal Opportunity Employer/Disability/Veteran.