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Medical
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PS27144 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 healthcare.

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:  This position is office-based on the east side of Louisville, KY.

Hours:  Hours will be 8:30 am - 5:00 pm during orientation/training.  Once completed, regular work hours will be 9:30 am - 6:00 pm, Monday through Friday, along with a rotating schedule to cover Friday until 7:00 pm.


Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and to promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs or community resources. 

 

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, high 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.
  • Works with medical directors in interpreting appropriateness of care and accurate claims payment. 
  • May also manage appeals for services denied.



  • Requires current active unrestricted Kentucky RN license to practice as a health professional within the scope of practice in Kentucky.
  • 2+ years inpatient acute care clinical experience is required.
  • 2+ years of hospital experience is required.
  • A.S. in Nursing is required; B.S. in Nursing is preferred.
  • Utilization Management/Review experience is strongly preferred.
  • Managed Care experience strongly preferred.
  • Basic Microsoft Office proficiency is required (Word, Excel, Outlook).
  • Proficient computer and typing skills are required.
  • Ability to work a 40 hour shift, with the ability to work a varied shift to cover hours of operation, is required.
  • Ability to work holiday hours is required.
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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