Seven Hills, Ohio

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 Management  I/II

Hours: 8:30-5:00pm EST, Monday-Friday. May require 2-3 evenings per month until 8:00pm EST and 1-2 Saturday shifts per quarter.

Location: Indiana or Ohio states required. Work at Home within a reasonable distance to Anthem office in the State of Indiana or Ohio.

 

Responsibilities:

Responsible for collaboration with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.

 

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 precertification, 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.
  • Consults 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.

Qualifications

Minimum Requirements:

  • Requires current active unrestricted RN license to practice as a health professional in State of Residence and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
  • Position is work from home. Must reside within a reasonable commuting distance to Anthem office occasional meetings, trainings, etc.

 

Preferred Qualifications:

  • Prior managed care experience.
  • UM experience.
  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

 

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. 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.

Seven Hills, Ohio

If you’re a reserve or veteran member of the military, 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 with operations experience.  Whether your experience is hands-on as an operational specialist or in operational leadership, 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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