, Georgia

Description

SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our VisionAt 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 I/II- $3000 sign on bonus
Location: This position will allow you to work remotely as long as you reside within a reasonable commuting distance to an Anthem office.  *Weekends are required plus 3 days during the week.
 
Summary: The Nurse Medical Management l/II positions are 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 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. 

 
Nurse Medical Management ll

The level ll Nurse Medical Management responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in intradepartmental teams, projects and initiatives. 


We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

An Equal Opportunity Employer/Disability/Veteran.

Qualifications

Qualifications: 

  • All levels require current active unrestricted RN license to practice as a health professional within the scope of practice in the state where you reside and 2 years acute care clinical experience.
  • Utilization Management / Review experience required.
  • Managed Care / Health Insurance experience preferred. 
  • MS Word and Excel proficiency preferred.

 

, Georgia

If you are active-duty military, reserve, or a military veteran, we foster a welcoming environment that’s dedicated to honoring your service and helping you achieve your career goals. Veterans of Anthem — one of our Business Resource Groups — partners with our Talent Acquisition teams to maximize career offerings for you and your family members, striving to help you transition to civilian service and grow your career at the same time. 

Join Anthem's Military and Veteran Talent Network: https://anthemcareers.ttcportals.com/pages/military 

WE ARE HIRING

Anthem, Inc. is currently seeking military veterans and military spouses for a variety of open roles.  Our immediate needs include Support Technical Engineer, Lead Engineer, Developer, Systems Analyst, Network Data Specialist, and Provider Network Manager roles.  Whether you are looking to transition into an IT career or if you have experience under your belt in the Technology field, Anthem wants to have an impact on your career and professional growth by speaking with you about their career opportunities.

If you are interested in learning more, check out Anthem's current open positions to the right for more information and to apply today!

Not sure where to start?  Send RecruitMilitary Success Manager, Taylor Groves, your questions at taylor.groves@recruitmilitary.com 

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