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Medical
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PS19728 Requisition #
Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. company, 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.

CLINICAL CAREER FAIR ON 7/24 AND 7/25 IN RALEIGH-DURHAM area!


This position is Sign-On Bonus eligible!


Location:   This position is located in all regions.  Some positions will be remote, and others will be office-based.

 

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 RN license to practice as a health professional within the scope of practice in North Carolina and 2 years clinical experience.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. 
  • Health Insurance/Managed care experience a plus.
  • Utilization management experience a plus.
  • Ability to resolve issues diplomatically with external resources.
  • Must reside within Raleigh-Durham, NC area.

 

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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Total Rewards

Explore Anthem, Inc.'s Total Rewards

Total Rewards is Anthem, Inc.'s overall program of benefits – from health care coverage to a winning culture and everything in between. We know that one size does not fit all when it comes to personal decisions about things like balancing your work and home life or saving for your retirement. That’s why our program is specifically designed to offer associates flexibility and choice.

Click the links below to learn more about Anthem, Inc.'s Total Rewards, and then use the "Flextimator" to model your approximate bi-weekly costs for the benefits in which you might choose to enroll.

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