Anthem, Inc. Nurse Case Manager l - CalAim Special Programs in Fresno, California
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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 Case Manager l – CalAIM Special Programs (PS65964)
Location: This is a work@home position, 100% telephonic. You must reside in the state of California.
Work Hours: 8am – 5pm, Monday – Friday.
The Nurse Case Manager l for Special Programs is responsible for collaborating with healthcare providers, community-based organizations, and members to promote quality member outcomes; to optimize member benefits; and to promote effective use of resources related to the Health Homes Program, palliative care service, medical nutrition therapy, and other SDoH projects. This position will also support the implementation of the Enhanced Care Management as new benefit where the Case Manager partners with external Interdisciplinary Teams and acts as a direct liaison to external providers and coordinates specific health services to address objectives and goals identified during assessment and care planning activities. He/ she performs care management/coordination activities within the scope of licensure for members served through these programs, and partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.
Primary duties may include, but are not limited to:
Works with external providers/case managers to implement and coordinate care plans specific to Whole Person Care, Health Homes, and palliative care; monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Ensures an assessment is completed and a health service plan is developed that is person centric in establishing goals and objectives aimed at preventing adverse health episodes and maintaining/ promoting health of members.
Works with external partners to ensure member access to medically necessary, quality healthcare in a cost-effective setting.
Acts as a direct liaison to external care teams and assists with implementation of care plans by coordinating internal resources to meet member needs, and by facilitating authorizations/referrals appropriate within the benefits structure.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Facilitates member care transitions through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required.
Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.
Conducts care coordination reviews to ensure compliance with applicable criteria, medical policy, and member eligibility and benefits.
Advocates with healthcare providers on behalf of members.
Performs duties telephonically.
Minimum R equirements:
Three years of either acute care clinical, condition specific clinical, home health/discharge planning, case management, or disease management experience; at least 1 year in a Nurse Care Manager role; or any combination of education and experience which would provide an equivalent background.
Current, unrestricted RN license in California.
Must reside in the state of California.
Must have 1+ years of experience in a role where coordination of specific needs and challenges of high-risk populations were part of the job responsibilities, i.e. Homeless, High Utilizers, SMI/SUD, Nursing Facility transition to community, LTC at risk for institutionalization; Incarcerated transition to community, and high-risk children and youth.
Must be able to work 8am – 5pm, Monday – Friday.
Experience in working with the Medi-Cal population, including but not limited to seniors, persons with mental or physical disabilities, individuals with chronic medical conditions, or individuals who are homeless.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
PC skills (Word, Excel, Outlook).
Experience in program implementation of community-based services.
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. 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. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.