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Anthem, Inc. Nurse Medical Mgmt I in West Covina, California

Nurse Medical Mgmt I

Location: United States

Requisition #: PS31112

Post Date: Jan 07, 2020

YourTalent. 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 ofhealth 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 benefits companies and a Fortune Top 50 Company.

NurseMedical Mgmt I

Location: Dallas/Forth Worth Texas

Texas residency required.

This is a remote opportunity after completing up to 90 days ofin-office training in the Grand Prairie, Texas office.

In this position, you are responsible to collaborate telephonically with healthcare providers (primarily physicians) and hospital case managers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

Primaryduties may include, but are not limited to:

  • Conductspre-certification, continued stay review, care coordination and dischargeplanning for appropriateness of treatment setting reviews to ensure compliancewith applicable criteria, medical policy, and member eligibility,benefits, and contracts.

  • Ensuresmember access to medically necessary quality healthcare in a costeffective setting according to member contract.

  • Consultswith clinical reviewers and/or medical directors to ensure medicallyappropriate, high quality, care throughout the medical management process.

  • Assessesthe medical necessity of outpatient services, focused surgical anddiagnostic procedures, out of network services, and appropriateness oftreatment setting.

  • Utilizesthe applicable medical policy and industry standards, accuratelyinterprets benefits and managed care products.

  • Steersmembers to appropriate providers, programs or community resources.

  • Collaborateswith providers to assess members' needs for early identification of andproactive discharge planning.

  • Facilitatesmember care transition through the healthcare continuum and referstreatment plans/plan of care to clinical reviewers as required and doesnot issue non-certifications.

  • Facilitatesaccreditation by knowing, understanding, correctly interpreting, andaccurately applying accrediting and regulatory requirements and standards.

  • Workswith medical directors in interpreting appropriateness of care andaccurate claims payment.

  • Mayalso manage appeals for services denied.

  • Current, active, unrestricted RN licensefrom the state of Texas.

  • 2 plus years acute care clinicalexperience is required.ICU, Med/Surg,ER exp preferred.

  • Utilization Management experience isstrongly preferred.

  • Managed Care and/or Medicaid experienceis preferred.

  • Knowledge of Facets a plus.

  • Computer proficiency in Microsoft Word,Excel, and Outlook is required, along with proficient typing skills andthe ability to use a laptop computer.

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.