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Nurse Medical Mgmt I/II/Sr - Virginia (PS4605VMJ) in Virginia Beach, VA at Anthem, Inc.

Date Posted: 4/11/2018

Job Snapshot

Job Description

Anthem, Inc. is one of the nation's leading health benefits companies and a Fortune Top 50 company. At Anthem, Inc., we are working together to transform health care with trusted and caring solutions.
 
Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people’s lives, and to take your career further than you can imagine.

 
Nurse Medical Management I/II/Sr
Telecommuting available once training is fully completed and the individual has demonstrated the ability to work independently.

Work Schedule: Full-time dayshift regular business hours Monday – Friday 8:00 am - 5:00 pm EST.

As a Nurse Medical Management associate, you will responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:

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.
 
Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment.

May also manage appeals for services denied.

Conducts pre-certification, inpatient, retrospective, out of network and 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.

Job Requirements

Nurse Med Mgmt I
Requires 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in the State of Virginia required. AS/BS in nursing preferred.
Nurse Med Mgmt II
Requires AS/BS in nursing; 3 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in the State of Virginia required. 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 preferred.
Nurse Med Mgmt Sr
Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the State of Virginia and 7 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. The following are level distinctions not required for posting. This level serves as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, may lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.
 
Preferred  
  • Prior telephonic medical management experience.
  • Utilization management experience.
  • Working knowledge in:   Trimed, MCG, AIMS and CCB.
 
***Position may be a Nurse Medical Management I, II, or Sr depending upon level of incumbent's education and relevant experience.***
 
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 please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.