Anthem Nurse Medical Mgmt I or II - Remote in anywhere of California - PS13590 in La Mirada, California

Nurse Medical Mgmt I or II - Remote in anywhere of California - PS13590

New

Location: California, United States

Field: Medical

Requisition #: PS13590

Post Date: 5 days ago

Your Talent. Our Vision. At Anthem Blue Cross , a proud member of the Anthem, Inc. family of companies, 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.

Nurse Medical Mgmt I or II – Remote in anywhere of California

Nurse Medical Mgmt I:

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 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.

Nurse Medical Mgmt II:

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:

  • 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.

  • 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.

Qualifications:

Nurse Medical Mgmt I:

  • Requires current active unrestricted RN license from the State of California to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.

  • At least 2 years’ acute care clinical experience required.

  • Previous Utilization Management experience is strongly desired.

  • Managed care experience is preferred.

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

Nurse Medical Mgmt II:

  • Requires current active unrestricted RN license to practice from the State of California.

  • At least 3-5 years acute care clinical experience required.

  • Previous Utilization Management is strongly desired.

  • Managed care experience is preferred.

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

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

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran.