Anthem RN Nurse Medical Management, UM - El Paso, Grand Prairie, Houston, or Lubbock, Texas PS11835 in Houston, Texas

RN Nurse Medical Management, UM - El Paso, Grand Prairie, Houston, or Lubbock, Texas PS11835


Location: Texas, United States

Field: Medical

Requisition #: PS11835

Post Date: Aug 23, 2018

mbination, 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.

Location : This position will work from one of the following offices for approximately the first 90 days (during the training period) and then will become remote. El Paso, Grand Prairie, Houston, Lubbock

Responsible for collaborating 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.

Primary duties may include, but are not limited to :

  • 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.

  • Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products, and steers members to appropriate providers, programs or community resources.

  • Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment.

  • 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 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.

  • Texas residency required.

  • Requires current active unrestricted RN license to practice as a health professional in state of Texas.

  • Minimum of 3 years acute care clinical experience required.

  • Utilization management experience required (post-acute setting preferred).

  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

  • Knowledge and understanding of Milliman Care Guidelines and InterQual criteria strongly preferred.

  • Prior case management experience preferred.

  • Prior managed care experience preferred.

  • Prior experience working with Medicaid population preferred.

  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

  • Must have strong Microsoft Office skills, especially Excel.

  • Experience with Facets highly desired.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2015 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at .