We have 3 new Nurse Med. Mgmt. positions due to the growth of our Medicaid membership in the West NY region. These are telephonic, remote (work from home) positions for experienced nurses with inpatient and outpatient utilization review experience. You will receive training and the equipment necessary for a home office. You do not have to live in the Buffalo area but it is preferred. You must have an active NY RN license.
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.
The Nurse Med Mgmt. 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.
-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.
-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, continued stay review, care coordination, or discharge planning for 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 a current active unrestricted RN license in the state of NY and a minimum of 3 years acute care clinical experience.
-Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
-Inpatient and outpatient utilization management experience preferred.
-Computer skills: MS Word, Outlook, Excel required. Must be confident and comfortable working on computers using multiple screens and web-based programs.
-Knowledge of Facets, CareCompass and Maccess a plus.
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 antheminc.com/careers. EOE. M/F/Disability/Veteran.
*WARNING : Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that an Anthem recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our careers require that you first complete an online application.