Anthem, Inc. Social Worker (myNEXUS) in Placentia, California
SHIFT: Day Job
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination. It’s 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.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.
Perform authorization activities for requested Home Health Services included as contracted services that meet eligibility and benefits coverage. Provide oversight to determine if the member is receiving appropriate services. Collaborate with home care agency, ordering/following physician(s), and MyNEXUS Medical Director(s) to discuss member’s current Plan of Care. Promote medically necessary and skilled services to ensure appropriate home care utilization. Refer member to health plan’s case management program as necessary. Recognize member safety issues and advocate for care in an environment that optimizes member safety. Responsible for authorization determinations and sending written authorizations to referring physician and home health care provider. Collaborates with agency social workers to discuss appropriate and/or additional services to assist or support individual members. When necessary, requests additional clinical information from member’s care providers. Refers requests that do not meet coverage guidelines criteria to Medical Director/Physician Review for a Level III Review. The care coordination component of the UM program is designed to identify and monitor delivery of home-based services in an efficient manner, responding to a member’s total health needs and ensure the highest quality of continuity of care.
DUTIES AND RESPONSIBILITIES:
Demonstrates Competency in the Following Areas:
Develop coordinated, collaborative care plans with all involved providers.
Review Home based services for clinical appropriateness of the continued care.
Performs reviews electronically using the member’s medical records and through discussion with home health agency staff.
Facilitates timely discharges from home care services and transfers to higher levels of care as appropriate.
Serve as information resource to patients, health care professionals, facilities, health plan representatives, caregivers and family members.
Monitor cost-effective use of resources.
Refer requests that do not meet coverage guidelines criteria to myNEXUS Medical Director or Physician for a Level III Review.
Acts as a liaison between myNEXUS team and managed care organization case managers .
Researches community resources to explore multiple options of care to assist members and provide further insight for clinical decisions.
Is responsible for authorizations to be completed and proactively escalates those cases that are at risk of not being completed within specified time frames as outlined in department policy.
Applies clinical judgment in conducting authorization review.
Distributes appropriate authorization letters to providers and members in compliance with department policies and time frames.
Follows process for acquiring additional clinical information/orders as needed for incomplete authorization requests.
Makes proactive outreaches to providers for clinical discussion.
Consults with Team Lead, Clinical Advisor, or myNEXUS Medical Director(s) if there are questions regarding the case meeting clinical criteria.
Handles all member and provider complaints appropriately and escalates complaints to department Team Lead or supervisor for further action and resolution.
Maintains and respects confidentiality of member’s personal health information.
Responsible for accurate review and entry of authorization data into computerized database.
Collaborates with members of the Quality and Appeals teams when requested.
Recognizes member safety issues and advocates for care in an environment that optimizes member safety.
Knowledgeable of current Medicare and Medicaid requirements, necessity and justification requirements.
Maintains good rapport with physicians, providers, and health plan representatives.
Maintains a good working relationship both within the department and with other departments.
Consults other departments as appropriate to collaborate in member care and performance improvement activities.
Participates in performance improvement activities for department and CQI activities.
Accepts additional assignments willingly.
Adheres to dress code, appearance is neat and clean.
Completes annual education and licensure requirements.
Maintains member confidentiality at all times.
Reports to work on time and as scheduled, completes work within designated time.
Follows all company policies related to time records.
Completes in-services in a timely fashion.
Attends monthly/annual reviews and department in-services, as scheduled.
Attends at staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Complies with all organizational policies regarding ethical business practices.
Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.
Bachelor’s Degree or equivalent
Specialty license or certification
Ability to read and communicate effectively in English.
Additional languages preferred.
Basic computer knowledge such as Word and Excel.
Excellent customer service and follow-up skills
Ability to sit for long periods and read monitors.
Strong attention to detail
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.