Anthem, Inc. Licensed Utilization Review II in Nashville, Tennessee
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.
COVID Notice: Due to the current COVID-19 (coronavirus) pandemic, this position will require you to work remotely from your home with the flexibility to return to a regular, in-office work environment if applicable. As we continue to monitor guidance from CDC and state officials there may be times you would need to report to the office on a monthly or quarterly basis for team meetings or engagement activities. As a Customer Care Representative, you will act as a trusted advisor and educator on health care related inquires. You will guide our customers to a better healthcare experience, working every day to make healthcare easy by the service you provide. If you want to be a part of this exciting team, make a difference in someone’s life, and help make healthcare easy, apply today!
Licensed Utilization II Job Summary: Responsible for working primarily with healthcare providers, taking inbound calls and making outbound calls, 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 is a call center nurse position. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include pre-noted inpatient admissions, outpatient services such as surgeries, DME, and 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 which require nursing judgment.
Primary Duties: Primary duties may include but are not limited to: Receiving inbound calls to conduct prior-authorization reviews for inpatient, outpatient requests, 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 relationships 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.
What Anthem Offers: 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. An Equal Opportunity Employer/Disability/Veteran
Requirements: • Requires a LPN, LVN, or RN; • 2 years of acute clinical care or utilization review experience; • 1 year of managed care experience and knowledge of the medical management process; 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 practice in applicable state(s) or territory of the United States required. • Current unrestricted license or certification in applicable state(s) required. • For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.