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 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.

Location: This position is eligable to work remote, but candidate must be within an hour of an Anthem northeast office with abilty to go onsite if necessary for IT or other needs. Tri-state locations are preferred.

***Position may be a Nurse Medical Management I, II, or Sr depending upon level of incumbent's education and relevant skills/experience.***

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 admission, continued stay review and initial skilled nursing facility and inpatient rehab admission review. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care

Primary duties may include, but are not limited to:

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 members needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers to medical director as required
Correctly interprets and applies appropriate regulatory requirements and standards

Qualifications

Requires an AS/BS in nursing; 2 years of acute care clinical experience (3 years and 5 years respectively for higher level); or any combination of education and experience, which would provide an equivalent background.
Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 2 years acute care clinical experience.
Must have current or previous utilization management experience.
Experience with DSNP and or Medicaid/MLTSS benefits a plus.
Discharge planning, skilled nursing facility (SNF) and/or rehabilitation experience strongly preferred.
Knowledge of MCG, Inpatient Surgical (ISC) and General Recovery Guidelines (GRG) strongly preferred. Knowledge of Medicare Benefit Policy as it applies to SNF and inpatient rehabilitation strongly preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Must have good typing skills and abiilty to work with various computer software.
Ability to multitask and prioritize daily tasks.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 Diversity Inc 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

Nurse Medical Mgmt I - Northeast Region - Military Veterans

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