This site uses cookies. To find out more, see our Cookies Policy

Nurse - RN - Utilization Management or Review / Precert - Telephonic - Louisville office (PS8441) in Louisville, KY at Anthem, Inc.

Date Posted: 9/28/2018

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.
 
Location: Louisville, KY office (Telephonic Call Center Environment)
 
Work Hours: Our shifts range between 8am and 6pm, Monday - Friday. You will be required to work a set schedule.
 
The Nurse Medical Management l 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. 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.

Requires:
 
  • AS/BS in nursing; 2 - 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent  background
  • Current unrestricted RN license in Kentucky is required.
  • Utilization Management (UM) / Review (UR) / Precertification experience
  • Call Center/Telephonic UM, UR or Managed Care experience 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 antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran.

CHECK OUT OUR SIMILAR JOBS

  1. Nurse Jobs
  2. RN Jobs