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RN Utilization Management - Nurse Medical Mgmt Lead - Atlanta, GA - PS22326

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Medical
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PS22326 Requisition #

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. 

 

RN UM - Nurse Medical Management Lead - PS22326

Location: Atlanta, GA Office


Georgia RN Licensure required


Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. 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: 

• Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

• Conducts precertification, 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 current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 5 or more years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. 
• RN Licensure in the state of Georgia is required.
• 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. 

Must be able to work in the Atlanta, GA office.

For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

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Atlanta, Georgia, United States

📁 Medical

Requisition #: PS22327

Be Part of an Inclusive Culture

Workforce Diversity

At Anthem Inc., we believe that having a diverse workforce is critical to innovation and to addressing the needs of the diverse customers and communities we serve. Women make up 76% of our workforce and 63% of all management roles. People of color represent 43% of our workforce and 29% of management. More about the breakout of our workforce in Anthem Corporate Responsibility.

Workforce Recruitment

Our commitment to improving access to affordable care while simplifying the health care experience for consumers requires the best talent, passion, broad insight and experience, and an innovative mindset.

We partner with external organizations, colleges and universities, and our nine associate resource groups to recruit, retain, and develop a workforce that reflects the communities we serve -- and to implement best practices to offer an inclusive environment for all. Our partnerships include: UNCF, United States Business Leadership Network (USBLN); National Association on Disability (NOD), Amerigroup National Advisory Board; Easter Seals; Job Accommodation Network (JAN); MindShift; VeteranRecruiting; HirePurpose; Hiring Our Heroes; Military Spouse Corporate Career Network; Out & Equal; Hispanic Association on Corporate Responsibility (HACR); Diversity Best Practices, among many others.

Associate Resource Groups

Our nine Associate Resource Groups (ARGs) include associates from all areas of the organization, multiple locations and a wide-range of experiences and backgrounds. The groups encourage diversity of perspectives and insight and help put the passion of our associates into action in order to make a real difference for our consumers and the communities we serve. Our ARGs help tackle business issues, participate in community programs, and facilitate opportunities for education, development, and networking. ARGs are open to all Anthem associates.

  • ABLE: Disability Inclusion Network Abilities Beyond Limited Expectations
  • ACE Asians Committed to Excellence
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  • WIN Women’s Inspired Network

LGBTQ inclusion – SAFE Space and Gender Transition Guidelines

We are proud to be recognized by the HRC among the Best Places to Work for LGBTQ Equality by obtaining a perfect score in the Corporate Equality Index. Our PRIDE ARG helps us identify and implement best practices and programs such as the Anthem Safe Space Program, the Gender Inclusion and Transition Guidelines, and Transgender Training for customer-facing associates. This ARG also helped create “Building an LGBT –Friendly Practice”, an online training module that we offer to all health care providers.

People with Disabilities

We have a strong commitment to the employment of people with disabilities and partner closely with external organizations and our ABLE ARG to nurture a culture and a physical environment that are both inclusive of associates as well as customers with disabilities. We have received the Leading Disability Employer Seal by NOD (2016-2017), a perfect score in the USBLN’s Disability Equality Index since 2016 and the Portlight “Getting It Right” Award in 2017 for our work in disaster preparedness and recovery for people with disabilities.

Veterans

It's important to us to offer our veterans opportunities to take their career in a new direction because we believe their spirit of service is essential to improving health care. Our VOA ARG partners with Talent Acquisition to maximize our ability to attract and retain veterans and their family members. The group also focuses on supporting our troops by sending care packages during the holidays and participating in events year-round. Learn more in our veterans’ page.

Unconscious Bias training

We train our leaders to make more informed and effective decisions by mitigating unconscious bias. There’s extensive research about the impact of unintended bias in decisions that affect people in the workplace so in 2017 we launched “Decide: The Neuroscience of Breaking Bias,” an eLearning experience that helps leaders identify, label and take action to minimize bias in order to build effective and inclusive teams.

Connect With Our Communities

Our associates are passionate about serving our members and giving back to the community and the company supports these efforts through several programs.

Year-round, Anthem associates give generously to health-related nonprofit organizations across the country through our Associate Giving Program, which offers a 50 percent match from the Anthem Foundation.

The Dollars for Doers program encourages year-round associate volunteerism—and helps associates’ commitment go even further by providing grants to eligible organizations where the volunteer service is completed. In 2017, our associates logged over 55,000 hours! To make it even easier to volunteer, associates can have up to eight hours of paid volunteer time off each year to be used to volunteer at qualified charities of their choice.

The Volunteer Recognition Program invites Anthem associates to share their volunteer stories or nominate their colleagues who volunteer in the community. Each quarter associates nominate and vote for a winner who exemplifies our value of Caring for Our Communities. The winner chooses an eligible charity to receive a special grant from the Anthem Foundation.

Learn more about how Anthem associates give back to their communities.

 
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