Anthem, Inc. RN Utilization Review I in Lexington, Kentucky
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater 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.
RN UM I
Locations: Position is W@H, must be located in KY, and hold a KY RN license.
Hours: 9:00 am - 6:00 pm EST
*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 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.
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 and 2 years acute care clinical experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Experience with Interqual, Milliman guidelines preferred
Previous UM experience preferred
An Equal Opportunity Employer/Disability/Veteran