Anthem, Inc Nurse Medical Mgmt I - CA - PS16389 in San Jose, California

Nurse Medical Mgmt I - CA - PS16389

Location: California, United States

Field: Medical

Requisition #: PS16389

Post Date: Jan 04, 2019

Your Talent. OurVision. AtAnthem, 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.

Nurse Medical Mgmt I

Location: CA - preference of southern CA

The Nurse Medical Mgmt I is 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 stayreview, care coordination, or discharge planning for appropriateness oftreatment setting reviews to ensure compliance with applicable criteria, medicalpolicy, and member eligibility, benefits, and contracts.

  • Consult with clinical reviewers and/or medicaldirectors to ensure medically appropriate, high quality, cost effective carethroughout the medical management process.

  • Collaborates with providers to assess member’sneeds for early identification of and proactive planning for dischargeplanning.

  • Facilitates member care transition through thehealthcare continuum and refers treatment plans/plan of care to clinicalreviewers as required and does not issuenon-certifications.

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

  • Requires current active unrestricted RN licenseto practice as a health professional in California.

  • At least 2 years acute care clinicalexperience

  • Medical review, clinical appeals, and/orutilization review experience preferred.

  • Proficient with internetnavigation.

  • Experienced working with Microsoft Outlook,Excel, and Word.

  • Requires strong oral, written and interpersonalcommunication skills, problem-solving skills, facilitation skills, andanalytical skills.

Note: This is a full-time, non-telephonic (i.e., no member and provider contact), work-at-home position. Must reside in California and must reside within 60 miles of an Anthem office.

Anthem, Inc. is rankedas one of America’s Most Admired Companies among health insurers by Fortunemagazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. Tolearn more about our company and apply, please visit us EOE. M/F/Disability/Veteran.