Nurse Medical Mgmt I, II Or Sr (Job Family)

Anthem, Inc. Richmond , VA 23234

Posted 1 week ago

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 Mgmt I, II or Sr (Job Family)

Location: Richmond, VA

Hours: 8 am to 5 pm EST

Please note: this position may be filled at either the Nurse Med Mgmt I, II or Sr. level. The hiring manager will determine level, based on the candidate's experience and background.

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and to 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 medical 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.

Qualifications

For all levels Utilization Management experience and working knowledge of Microsoft Office is strongly preferred.

Nurse Med Mgmt I

  • Requires 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted RN license from the state of Virginia or current unrestricted Compact RN license is required.

Nurse Med Mgmt II

  • 3 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted RN license from the state of Virginia or current unrestricted Compact RN license is required.

  • Participation in the American Association of Managed Care Nurses preferred.

  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

  • Prior managed care experience preferred.

Nurse Med Mgmt Sr.

  • Current unrestricted RN license from the state of Virginia or current unrestricted Compact RN license is required.

  • 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.

  • Participation in the American Association of Managed Care Nurses preferred.

  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. Prior managed care experience required.

  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Must exhibit leadership skills.

  • This level serves as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, may lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

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Nurse Medical Mgmt I, II Or Sr (Job Family)

Anthem, Inc.