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Anthem, Inc. Nurse Case Manager I/II in Wallingford, Connecticut

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 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 benefits companies and a Fortune Top 50 Company.

Nurse Case Mgr I

Responsible for performing high quality medically appropriate cost effective care in case management within the scope of licensure for members with complex and chronic care needs by collaborating with healthcare providers and/or consumer to drive personalized health management and improve health and optimal outcome for consumers.

Performs telephonic case management activities within the scope of licensure for members with complex and chronic care needs. Primary duties may include, but are not limited to d ischarge planning, post discharge management and other care management activities base on need of member or department. Responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum.

Primary duties may include but not limited to the following.

  • Ensure member access to services appropriate to their health needs.

  • Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.

  • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.

  • Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

  • Coordinates internal and external resources to meet identified needs.

  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

  • Partners with the members’ physicians, physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.

  • Conducts clinical assessment to develop goals that address individual needs in order to develop and implement a care plan.

  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

    Nurse Case Manager II

    Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Performs care management activities within the scope of licensure for members with complex and chronic care needs.

    Primary duties may include, but are not limited to:

  • Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care.

  • Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.

  • Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.

  • Conducts clinical assessment to develop goals that address individual needs in order to develop a care plan; implements and coordinates a care plan.

  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

  • Assists with development of utilization/care management policies and procedures.

  • Participates in or leads intradepartmental teams, projects, and initiatives as directed.

  • May assist with Precepting new case/care management staff.

Qualifications

Nurse Case Mgr I

  • Requires 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

  • Current, unrestricted RN license in applicable state(s) required.

  • Multi-state licensure is required if this individual is providing services in multiple states.

  • Home health/discharge planning experience preferred. AS/BS in nursing preferred.

  • Certification as a Case Manager is preferred.

  • Requires3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states.

  • Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field also preferred.

  • For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows an independent assessment to be conducted within their scope of practice.

  • Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states.

  • Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field also preferred.

Nurse Case Manager II

  • Requires 3 years of acute care clinical experience, condition specific clinical experience, home health/discharge planning experience; at least 1 year in a Nurse Care Mgr I role or equivalent experience; or any combination of education and experience, which would provide an equivalent background.

  • Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. AS/BS in nursing preferred.

  • Certification as a Case Manager is preferred.

  • Participation in the American Association of Managed Care Nurses preferred.

  • Prior managed care experience preferred.

  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

  • For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice.

  • Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background,

  • Multi-state licensure is required if this individual is providing services in multiple states .

  • Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field, also preferred.

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.

REQNUMBER: PS49364

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