Nurse Medical Mgmt I, II or Sr - Eastern Region - Anthem, Inc (Arkansas)
Description
SHIFT: Day Job
SCHEDULE: Full-time
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.
Preferred Location: Must reside in the Eastern Region states.
Qualified candidate must reside within a 1 hour driving distance to an Anthem
office.
***Position may be filled at the Nurse Medical Management I or II or
Senior level depending upon level of incumbent's education and relevant skills /
experience.***
The Nurse Medical Management l and ll are 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 admission, continued stay
review and initial skilled nursing facility and inpatient rehab admission
review. Applies clinical knowledge to work with facilities and providers
for care coordination. Works with medical directors in interpreting
appropriateness of care. Primary duties may include, but are not limited to:
+ Conducts pre-certification, inpatient, retrospective, out of network and
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 to medical director as required.
+ Correctly interprets and applies
appropriate regulatory requirements and standards.
The Nurse Medical Mgmt Sr is 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.
Qualifications
Qualifications for I and II:
+ AS/BS in nursing; 2 years (Nurse Medical Management l) of acute care clinical experience (3 years and 5 years respectively for Nurse Medical Management ll); or any combination of education and experience, which would provide an equivalent background.
+ Requires current, active unrestricted RN license to practice as a health professional in the state where you reside.
+ Must have current or previous utilization management / review experience.
+ In the future, an occasional weekend day will be required with a day off during the week.
+ Experience with DSNP a plus.
+ Discharge planning, skilled nursing facility (SNF) and/or rehabilitation experience strongly preferred.
+ Knowledge of Milliman (MCG) strongly preferred.
+ Knowledge of Medicare Benefit Policy as it applies to SNF and inpatient rehabilitation strongly preferred.
+ Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
+ Must have good typing skills and the ability to work with various computer software programs.
+ Ability to multitask and prioritize daily tasks.
Qualifications for Senior level:
+ 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.
+ 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
+ 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.
+ Experience with DSNP and or Medicaid/MLTSS benefits a plus.
+ Discharge planning, skilled nursing facility (SNF) and/or rehabilitation experience strongly preferred.
+ Knowledge of MCG, Inpatient Surgical (ISC) and General Recovery Guidelines (GRG) strongly preferred.
+ Knowledge of Medicare Benefit Policy as it applies to SNF and inpatient rehabilitation strongly preferred.
+ Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
+ Must have good typing skills and the ability to work with various computer software.
+ Ability to multitask and prioritize daily tasks.
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.
REQNUMBER: PS42387
* This article was originally published here
