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Nurse (RN) Utilization Management l or ll / Hospital Review - NY, NJ, or CT preferred (PS15318) in New York, NY at Anthem, Inc.

Date Posted: 1/7/2019

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.
Location:  Candidates in NY, NJ, or CT preferred. Will consider candidates on the East Coast. If external, candidates must be able to work from local Anthem office and may allow work@home opportunity in the future.
The Nurse Medical Management l or ll is responsible for collaborating 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 for the Medicare Advantage through Hospital Review process. 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.
  • 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.
  • May participate in or lead intradepartmental teams, projects and initiatives.

  • 2 years of acute care clinical experience (3 years for level ll); or any combination of education and experience, which would provide an equivalent background.
  • AS/BS in nursing preferred.
  • Current unrestricted RN license in state where you reside.
  • Hospital review experience required.
  • Must be able to work East Coast Time Zone.
  • Knowledge and experience in Medicare Advantage health plans with a good understanding of CMS rules and regulations strongly preferred.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.