Anthem Nurse (Pre-Certification experience) NV Medicaid - REMOTE (PS9521) in Miami, Florida

Nurse (Pre-Certification experience) NV Medicaid - REMOTE (PS9521)

Location: United States

Field: Medical

Requisition #: PS9521

Post Date: Jul 10, 2018

Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving

Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.

Preferred Location: This position will allow you to work from home. Nevada residence preferred.

Other Locations: Anywhere in the United States

Work Hours: Pacific Coast Time Zone - 8am - 5pm.

The Nurse Medical Management l is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize outpatient 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. 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, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure.

  • Functions may include review of claim edits, pre-noted inpatient admissions, and/ 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.

  • 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.

  • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requires:

  • Current, active unrestricted Nevada RN license - Minimum 2 years acute care clinical experience.

  • Strong computer skills.

  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Preferred:

  • Utilization Management / Pre-certification.

  • InterQual experience strongly preferred.

  • Managed care.

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 please visit us at antheminc.com/careers. Equal Opportunity Employer. M/F/Disability/Veteran.