Anthem, Inc. Nurse Medical Mgmt I/II/Sr in Upland, California
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 benefits companies and a Fortune Top 50 Company.
Nurse Medical Management I/II/Sr
Location: Remote - Work at Home
Work schedule: Normal business hours are Monday - Friday 8:30am - 5:00pm EST with option of 10 hour workdays based on business needs.
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 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 pre-certification, 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 accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards
Current active unrestricted RN license from the state you reside and 2 years acute care clinical experience or case management, utilization management or managed care experience required
Prefers strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Knowledge of the interpretation and application of member contracts, member benefits, and managed care products
Utilization Management experience preferred.
Familiarity with ACMP preferred.
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.
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.