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Anthem, Inc Licensed Utilization Review I in Tampa, Florida

Licensed Utilization Review I

Location: Tampa, Florida, United States

Requisition #: PS25629

Post Date: Aug 23, 2019

Licensed Utilization Review I

Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care,home health, durable medical equipment,radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.

Primary duties may include, but are not limited to:

  • Conducts pre-certification, inpatient (ifnot associated with CM or DM triage) retrospective, out of network andappropriateness of treatment setting reviews within scope of licensure byutilizing appropriate medical policies and clinical guidelines incompliance with department guidelines and consistent with the memberseligibility, benefits and contract.

  • Develops relationships with physicians,healthcare service providers, and internal and external customers to helpimprove health outcomes for members.

  • Applies clinical knowledge to work withfacilities and providers for care coordination. May access and consult withpeer clinical reviewers, Medical Directors and/or delegated clinicalreviewers to help ensure medically appropriate, quality, cost effectivecare throughout the medical management process.

  • Educates the member about plan benefits andcontracted physicians, facilities and healthcare providers.

  • Refers treatment plans/plan of care to peerclinical reviewers in accordance with established criteria/guidelines anddoes not issue medical necessity non-certifications.

  • Facilitates accreditation by knowing,understanding, and accurately applying accrediting and regulatoryrequirements and standards.

  • Requires a LPN, LVN, or RN; 2 years ofclinical or utilization review experience; or any combination of educationand experience, which would provide an equivalent background.

  • Current active unrestricted license orcertification to practice as a health professional within the scope oflicensure in applicable state(s) or territory of the United Statesrequired.

  • Knowledge of the medical management processpreferred.

  • For URAC accredited areas the followingapplies: Requires strong oral, written and interpersonal communicationskills, problem-solving skills, facilitation skills, and analyticalskills.

Anthem,Inc. is ranked as one of America’s Most Admired Companies among health insurersby Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company forDiversity. To learn more about our company and apply, please visit us An Equal Opportunity Employer/Disability/Veteran