🌎
This job posting isn't available in all website languages
📁
Medical
📅
PS27833 Requisition #

CareMore is entering a new growth phase, as a proven care delivery model for the highest-risk.  We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.  We build and lead integrated, multi-disciplinary clinical teams to care for the most complex patients and currently serve nearly 200,000 patients in multiple states across Medicare, Medicaid, and commercial populations. We strive for excellence and have achieved significant and measurable improvement in total cost of care, clinical outcomes, and experience.  As an Anthem subsidiary, we benefit from the scale and resources one of America’s largest managed healthcare organizations.

 

CareMore’s Health Networks, Primary Care+, Touch and CareMore@Home models drive strategy, operations, and care delivery in our national markets (Arizona, California, Colorado, Connecticut, Iowa, Nevada, New York, Tennessee, Texas, Virginia and the District of Columbia), where CareMore builds and runs capitated primary care medical groups, at-risk health networks and upstream care delivery products in service of high-risk Medicaid, Medicare and commercial patients, and our collaboration with Emory Health System in Georgia. Our comprehensive, upstream approach to health is led by robust multidisciplinary teams of extensivists (managing acute and post-acute episodes of care), primary care clinicians, behavioral health clinicians, care management & engagement specialists (including social workers, case managers and community health workers), and mobile home-based care teams. We continue to evolve our model to effectively engage and care for complex patients, led by a team of passionate, execution-minded leaders dedicated to this mission.

Working in the Cerritos, California office is week day, Monday - Friday, 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 member’s 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 2 years acute care clinical experience. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
An Equal Opportunity Employer/Disability/Veteran
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 in Cerritos CA.
Monday - Friday, 8:00 AM - 5:00 PM 
WORKING IN THE OFFICE IN CERRITOS CA
Minimum of 1 year' experience with InterQual/MCG Guidelines required  
Experience with health plan UM/Concurrent review process

·    Experience with Denial Letters

2 years acute care clinical experience required  
2 years' experience with Health Plan Utilization Management, Concurrent Review Process and 2 years' experience with denial letters required. 
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. 
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 Diversity Inc 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.


Previous Job Searches

Activity Feed

29220
Job shares through Anthem, Inc.
Faith Cao referred the Business Information Analyst II position. 3 days ago
Michelle Smith referred the Manager Business Project & Support- PS29830 position. Feb 19, 2020
April Cook referred the Business Consultant (PS33436) position. Feb 18, 2020
Snehal Shah referred the Financial Pricing & Analysis Consultant - PS33285 position. Feb 11, 2020
Cassagnol Innocent referred the Investigator II-Remote in MD (PS32562) position. Feb 11, 2020

Similar Listings

Cerritos, California, United States

📁 Medical

Requisition #: PS33752

Cerritos, California, United States

📁 Medical

Requisition #: PS30527

Cerritos, California, United States

📁 Medical

Requisition #: PS32611

Your Skills.
 Our Opportunities

As one of America’s largest health benefits companies, we at Anthem have a profound appreciation for service. Our organization proudly supports our nation’s active, reserve and veteran military service members and their spouses.

This is an exciting opportunity to advance your life and career, while still protecting and serving others. Come see for yourself why Anthem is recognized as a Top Employer by GI Jobs and among the “Best of the Best: Top Veteran Friendly Companies” by US Veterans Magazine.

Find A Career

Skills Translator

Enter your Military Occupation Code (MOC) or military or civilian title into our Military Skills Translator tool to see related openings at Anthem for an improved experience locating careers that maximize your military skills

Use Translator