Anthem, Inc. Nurse Utilization Management l, ll or Sr – Complex Discharge Planning in Shelbyville, Kentucky
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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 Utilization Management l, ll or Sr – Complex Discharge Planning (PS44626)
* Note: This position may be filled at the Nurse Medical Management l, ll, or Sr. level depending on candidates’ skills, experience, and education. *
Location: Work from home. Must reside within 60 miles of an Anthem location.
The Nurse Medical Management l, ll, and Sr. levels are responsible to collaborate telephonically with healthcare providers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
Conducts pre-certification, 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.
Ensures member access to medically necessary quality healthcare in a cost effective setting according to member contract.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, care throughout the medical management process.
Assesses the medical necessity of outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting.
Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products.
Steers members to appropriate providers, programs or community resources.
Collaborates with providers to assess members' needs for early identification of and proactive 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
May also manage appeals for services denied.
Nurse Medical Management II responds to more complex medical issues, serves as resource to lower level nurses, and may participate in or lead intradepartmental teams, projects and initiatives.
Nurse Medical Management Sr. may serve as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, may lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives. Must exhibit leadership skills and have previous experience in a team lead or senior role.
Requires current, active, unrestricted RN license from the state where you reside.
Minimum 2 - 3 years acute care clinical experience is required. (3 – 5 years for the Level ll and Sr. roles required)
Utilization Management or Utilization Review experience is required.
Managed Care preferred and required for Sr. level.
Knowledge of Medicare is a plus.
Utilization Management discharge planning and case management strongly preferred.
Proficient using MS Word and MS Excel.
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 few. An Equal Opportunity Employer/Disability/Veteran.
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.
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