Anthem Nurse Medical Mgmt II - Remote in anywhere of California - PS9285 in Santa Barbara, California

Nurse Medical Mgmt II - Remote in anywhere of California - PS9285

New

Location: California, United States

Field: Medical

Requisition #: PS9285

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 II – Remote in anywhere of California

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.

  • This role will mainly cover for Triage.

Qualifications:

  • Requires current active unrestricted RN license to practice as a health professional in the state of California and 3-5 years case management, medical management, utilization management or managed care experience, which would provide an equivalent background.

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

  • At least 1 year experience in Triage strongly preferred.

  • Prior managed care experience preferred.

  • Certification in Case Management or Medical Management preferred.

  • Intermediate or above level in Microsoft Word, Excel, Outlook and PowerPoint preferred.

  • Experience with EMR (Electronic Medical Records) preferred.

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

  • This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.

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. EOE. M/F/Disability/Veteran.