/ Your Talent. Our Vision. / At Anthem Blue Cross and Blue Shield , a proud member of the Anthem, Inc. family of companies, 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.
Nurse Case Mgr Sr
Location: Any US location. Ohio strongly preferred.
As a Nurse Case Manager Sr, you will be responsible for 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 and care management for members who are enrolled in the Medicare Advantage (MA) health plan . This role will focus primarily working with MA members who are part of the new COPD program and other clinical programs.
Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to:
Ensures member access to services appropriate to their health needs.
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.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
Participates in department audit activities.
Requires a BA/BS in a health related field; 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in primary residence. Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager is preferred. For URAC accredited areas the following applies: Requires a BA/BS; 5 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in applicable state(s). 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 and a BS in a health or human services related field preferred.
May involve minimal travel (approx. 5%-10%).
Previous clinical experience working with Medicare eligible member/patient population.
Case management experience in Managed Care industry.
Clinical experience working with members to manage chronic conditions.
Experience using case management medical management system.
Experience in clinical research a plus.
Home health experience a plus.
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Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.
Title: Medicare Nurse Case Manager Sr (Remote) - 137009
Location: florida-Boca Raton
Other Locations: CA-San Diego, CO-Denver, OH-Akron, NV-Las Vegas, NY-Syracuse, OH-Canton, OH-Miamisburg, MO-St. Louis, IN-Indianapolis, CA-Costa Mesa, PA-Harrisburg, ME-South Portland, OH-Seven Hills, CT-Wallingford, OH-Youngstown, OH-Toledo, MA-Andover, IL-Chicago, OH-Columbus, OH-Cincinnati, OH-Mason, OH-Worthington, NY-Albany, OH-Cleveland, FL-Miami, OH-Lima, WV-Charleston, WI-Milwaukee
Requisition ID: 137009
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