/ 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 benefits companies and a Fortune Top 50 Company.
Location:Work from home in the state of Indiana after successful completion of training and along with proven satisfactory work performance.
TheNurse Medical Management Leadis 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
Requires current active unrestricted RN license to practice as a health profesional wihtin the scope of practice in applicable state(s) or territory of the United States and 5 or more years acute care clinical experience or case management, utilization management or managed care experience.
Certified Managed Care Nurse preferred
Must have knowledge of facets/macess
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
Project management experience required
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Must have advanced computer skills in MS office
Must exhibit leadership skills
The following are level distinctions not required for posting
/Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran./
Equal Employment Opportunity Statement
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: Nurse Medical Management Lead - Indianapolis, IN - #137099
Requisition ID: 137099
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