Anthem, Inc. Lexington , KY 40598
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.
Training Location: Initially you will work from our Louisville, KY office until training has been completed satisfactorily.
Work Location: Lexington, KY. This position will require you to spend a large part of your time at our provider facility/facilities. When not on-site, you will be able to work from your home office.
The Nurse Medical Management l is responsible for collaborating with the Kentucky Medicaid Health Plan provider(s) and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, 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. Works with medical directors in interpreting appropriateness of care and accurate claims payment. Primary duties may include, but are not limited to:
Conducts continued stay review, care coordination, and/or discharge planning for appropriateness of treatment to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Will research to identify options for transition from acute care to lower levels of care both locally and, when necessary, in other areas.
Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
Consults with medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers face-to-face 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.
Current active unrestricted RN license to practice as a health professional in the state of Kentucky and 2 years acute care clinical experience.
Knowledge of In-Patient Utilization Management / Review and discharge planning strongly preferred.
Clinical Case Management a plus.
Knowledge of Medicaid or Medicare criteria preferred.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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 antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran.