, Virginia

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.

Nurse Medical Management I or Nurse Medical Management II
Schedule: Monday-Friday, 6:00 am - 6 pm (EST)
Location: Remote-Hybrid

Duties & Responsibilities

Responsible to collaborate 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: 

Nurse Medical Management I

•    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 II

•    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

Requirements

Nurse Medical Management I
•    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 
•    Minimum of 2 years acute care clinical experience.
•    Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

Nurse Medical Management II
•    Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States. 
•    Minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background. 
•    Participation in the American Association of Managed Care Nurses preferred. 
•    Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
•    Prior managed care experience strongly preferred. Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred. The following are level distinctions not required for posting.
•    This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead 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. 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.

, Virginia

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 tech based roles.  Our immediate needs are in IT support, cyber security, maintenance of digital and automation systems, and network specialists. These roles 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.

Employee Benefits:

  • Paid Time Off
  • Dental Insurance Plan
  • Medical Insurance Plan
  • Employee Assistance Program
  • Flexible Spending Account
  • Life Insurance
  • 401(k) plan
  • Adoption Assistance
  • New Parent Transition Week
  • Parental Leave
  • Critical Caregiving Leave
  • Back-to-School Assistance
  • Sick Leave

What Happens After I Apply?

Once you click ‘Apply Now’ on an Anthem job posting, you will either be re-directed to fill out an application on Anthem's career page or be given a confirmation of submission.  If you get redirected, please complete the application on the career page and make sure you have an updated resume uploaded to your RecruitMilitary profile.  Once Anthem reviews your resume and profile, a recruiter will reach out to provide you with more information and to schedule you for an interview.

How to Win An Interview

1.     Review the job description for the specific position you are applying for.

2.     Review the company website. Know their mission and values. What do they do? What are their products?

3.     Prepare a few questions to ask on your interview.

4.     Prepare to discuss your military or civilian background and how it relates to the position. 

5.     Check out the RecruitMilitary Resources tab for resume guidance, interview prep and more!

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