Eagan, Minnesota

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 care companies and a Fortune Top 50 Company.

 

Our Government Business Division is focused on serving Medicaid, Medicare and uninsured individuals. The associate in this position will be supporting members enrolled in the Minnesota Medicaid Program. 

 

Work Location: In the future, this position will be office-based at our Eagan, Minnesota location. (Initially this position will be working from home until the office reopens.)

 

Work Hours: Monday – Friday, 8am - 5pm.

 

The Nurse Medical Management l is responsible to collaborate with healthcare providers 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, 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.  Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. 

 

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, 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.  

Qualifications

Requires:

  • Current active unrestricted RN license to practice as a health professional in the state of Minnesota and 2 years acute care clinical experience. 
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and 
  • Ability to analyze and resolve problems that are directly, or indirectly, caused by conflicting data.
  • Strong computer skills.
  • Requires knowledge of utilization management / review, preferably within the managed care industry. At a minimum, must have a working knowledge of prior authorization process.
  • Experience with outpatient nursing care preferred; this can include specialty clinics, surgery centers or community nursing.
  • Ability to multi-task and switch gears quickly and comfortable working in a productivity environment with a work queue.

 

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.

Eagan, Minnesota

At Anthem, Inc., we believe that our health connects us all. So we focus on being a valued health partner and delivering quality products and services that give members access to the care they need. With more than 100 million people served by our affiliated companies including approximately 40 million enrolled in our family of health plans, we can make a real difference to meet the needs of our diverse customers.

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