Nurse Medical Management I
Company: Anthem, Inc.
Posted on: May 3, 2021
SHIFT: Day Job
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.
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 care companies and a Fortune Top 50 Company.
Nurse Medical Mgmt I
Hours: Monday - Friday 8 am to 5 pm central time
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 from the
state of Texas.
- Candidate must reside in Texas.
- Minimum of 2 years acute care clinical experience is
- Utilization Management experience is strongly preferred.
- Managed Care and/or Medicaid experience is preferred.
- NICU/PEDs experience preferred
- Knowledge of Facets a plus.
- Computer proficiency in Microsoft Word, Excel, and Outlook is
required, along with proficient typing skills and the ability to
use a laptop computer
We offer a range of market-competitive total rewards that
include merit increases, paid holidays, Paid Time Off, and
incentive bonus programs (unless covered by a collective bargaining
agreement), medical, dental, vision, short and long term disability
benefits, 401(k) +match, stock purchase plan, life insurance,
wellness programs and financial education resources, to name a
Anthem, Inc. is ranked as one of America's Most Admired
Companies among health insurers by Fortune magazine and has been
named a 2019 Best Employers for Diversity by Forbes. To learn more
about our company and apply, please visit us at
careers.antheminc.com. An Equal Opportunity
Employer/Disability/Veteran. Anthem promotes the delivery of
services in a culturally competent manner and considers cultural
competency when evaluating applicants for all Anthem positions.
Keywords: Anthem, Inc., Lubbock , Nurse Medical Management I, Other , Lubbock, Texas
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