Nurse Utilization Mgmt I - Fhps / FEP - Anthem, Inc (California)
Description
SHIFT: Day Job
SCHEDULE: Full-time
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 benefits companies and a Fortune Top 50 Company.
Nurse Medical Management l – FHPS / FEP (PS42912)
Work Hours: You may reside in any time zone but must be able to work 9am – 5:30pm, or 9am - 6pm, Monday through Friday, Eastern Time Zone.
The Nurse Medical Management I is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
+ 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.
+ Applies clinical knowledge to work with facilities and providers for care coordination.
+ Works with medical directors in interpreting appropriateness of care and accurate claims payment.
+ May also manage appeals for services denied.
+ Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
+ Ensures member access to medical necessary, 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 member’s 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.
Qualifications
Requires:
+ 2 years of acute care clinical experience with utilization management / review; or any combination of education and experience, which would provide an equivalent background.
+ Current unrestricted RN license in the state where you reside.
+ AS/BS in nursing preferred.
+ Utilization Management experience preferred.
+ Managed Care experience a plus.
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. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
REQNUMBER: PS42912
* This article was originally published here