Anthem, Inc. Licensed Utilization Review Sr. in Hingham, Massachusetts
SHIFT: Day Job
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.
Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
This level works with the most complex elements and requires review of the most complex benefit plans. May also serve as mentor or preceptor for less experienced staff in addition to serving as department representative on various intradepartmental initiatives. May assist in formal training of associates and may be involved in process improvement initiatives within the utilization management function.
Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
Primary duties may include, but are not limited to:
• Conducts pre-certification, inpatient, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. • Develops working partnerships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. • Applies clinical knowledge to work with facilities and providers for care-coordination. • May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. • Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
Minimum Requirements: • Requires a RN. • A minimum of 2 years of clinical or utilization review experience. • A minimum of 2 years of managed care experience; or any combination of education and experience, which would provide an equivalent background. • Current active unrestricted license or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Preferred Qualifications: • Knowledge of the medical management process strongly preferred.
• Home Health experience preferred.
• For URAC accredited areas the following professional competencies apply: Associates in this role are expected to have 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.