Anthem, Inc. Nurse Medical Management Lead in Fond du Lac, Wisconsin
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.
Hours: 8am EST-5pm EST
The Nurse Medical Management Lead will be responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated 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: • Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. • 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. • 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 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.
• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 5 or more years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. • Certification in the American Association of Managed Care Nurses preferred. • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. • Prior managed care experience required. • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. • Must exhibit leadership skills.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.