Anthem, Inc. Nurse Medical Mgmt I/II in Hialeah, Florida
SHIFT: Day Job
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 at one of America's leading health care companies and a Fortune Top 50 Company.
LOCATION: This is a remote UM position servicing our Medicaid members in the eastern region. Connecticut residency is preferred, and the East coast region is required.
HOURS: Monday thru Friday, 8:00 am - 5:00 pm, EDT.
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources.
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 medically necessary, high-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 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.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Requires a current, active, unrestricted RN license from the state in which you reside, and a willingness to become licensed in other states as required for the position.
Requires 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
Requires knowledge of the medical management process, and the ability to interpret and apply member contracts, member benefits, and managed care products.
2 years of utilization review experience is required for Nurse Medical Mgmt II.
Prior managed care experience is preferred.
You must be agreeable to providing weekend coverage hours on a rotating basis.
You must be competent in Microsoft Word, Excel, and Outlook.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources, to name a few. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.