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Nurse Medical Management Future Opportunities California, 133046 in San Diego, CA at Anthem, Inc.

Date Posted: 11/25/2018

Job Snapshot

Job Description

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.

By applying to this posting, your resume will be captured as part of our talent pipeline for future job opportunities in California.  You may also view and apply through this website for other open roles.
Future Opportunities:

Nurse Medical Management
The Nurse Medical Manager is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. 
This person supports community based adult services or Centers for Medicare & Medicaid Services (CMS) for Home and Community-Based Services (HCBS). HCBS is a federal funding under the Medicaid program (called 'Medi-Cal' in California). 
He/she will work with medical directors in interpreting appropriateness of care and accurate claims payment.
Primary duties may include, but are not limited to:
  • Conducts precertification for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process
  • Facilitates accreditation and accurately applying accrediting and regulatory requirements and standards. 
  • Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background
  • Requires AS/BS in nursing
  • Participation 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 strongly preferred
  • Current unrestricted RN license in applicable state(s) required
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
  • Case management or LTSS experience preferred
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at EOE. M/F/Disability/Veteran.


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