Anthem, Inc. RN Utilization Management l or ll (Telephonic - 1 Weekend/month) in Cleveland, Ohio
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.
Nurse Medical Management l or ll (Rotating Weekends) PS59375
Location: This is a work@home position. Qualified candidates must reside within a reasonable commuting distance to any Anthem office.
Weekday Work Hours: Regular business hours, Monday - Friday. Must be willing to work an 8 hour shift beginning at 9am or 9:30am Eastern Time. Later hours may be available.
Rotating Weekends required : 1 Weekend per month required with 2 days off during that week to compensate.
The Nurse Medical Management l / ll positions are 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, 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.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Nurse Medical Management ll.
The level ll Nurse Medical Management responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.
Nurse Level l and Level ll
Current active unrestricted RN license to practice as a health professional within the scope of practice in the state where you reside and 2 years acute care clinical experience.
Utilization Management within managed care industry OR Utilization Review experience within hospital setting required.
Managed Care / Health Insurance experience required.
The Nurse Medical Management ll in addition to the above requirements:
3 – 5 years of acute care clinical experience or case management, utilization management or managed care experience, or any combination 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.
MS Word and Excel proficiency.
Applicable to Colorado Applicants Only
Annual Salary Range*: $58,720 - $86,940
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
- The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
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.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.