Anthem, Inc. RN Case Manager Lead - Population Health (UM and CM) in Seattle, Washington
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.
Nurse Case Manager Lead – PS41548
Location: May work from home but must reside within 1 hour commute to any Anthem office.
Work Hours: Applicants anywhere in the United States will be considered providing they are willing and able to work East Coast business hours.
The Nurse Case Manager Lead is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Assists team members in the delivery of case and utilization management programs; provides guidance and assistance with clinical, program, and client specific questions and situations. Performs duties telephonically for discharge planning. Primary duties may include, but are not limited to:
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
Participates in audit activities and assists manager with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager.
Serves as first line contact for conflict resolution.
Serves as resource to lower-level nurses; functions as preceptor for new care management staff.
Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.
BA/BS in a health related field; 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license in the state of residence. (Will require current, unrestricted RN license in the state of New York.)
Prior Case Management experience a plus.
Certification as a Case Manager is a plus.
Utilization Management Review process knowledge preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
Proficiency using computers and a variety of computer programs required.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.