/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 care for our members, greater value for our customers, and greater health for our communities. Join us and together we willdrive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Location: This is an office based position located at our St. Louis Office on
1831 Chestnut Street or Albany Office on 11 Corporate Woods Boulevard.
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 ensuring member access to services appropriate to their health needs. Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to:
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.
Negotiates rates of reimbursement, as applicable.
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 audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager.
Serves as first line contact for conflict resolution.
Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.
May take on small case load of MHA members.
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 Missouri or New York required. Certification as a Case Manager is 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.
Position will be client and consultant facing.
/Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at//www.antheminc.com/careers//. EOE. M/F/Disability/Veteran/
Title: RN Nurse Case Manager Team Lead - St. Louis, MO / Albany, NY - 122573
Location: MO-St. Louis
Other Locations: NY-Albany
Requisition ID: 122573
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