RN Nurse Medical Mgmt Sr. - Team Lead - Inpatient Review Team - Remote - Pine St., NY 136970
Location:
New York , New York
Posted:
November 21, 2017
Reference:
105344291
Your Talent. Our Vision. AtEmpire Blue Cross Blue Shield, a proud member of theAnthem, 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.

This position requires that you have a current, active, unrestricted NY RN license and live within commuting distance to our downtown NYC office at 9 Pine St. for purposes of training, meetings, etc. Following training (6-8 weeks) you will receive the necessary equipment to work from a home office.

ThisNurse Med. Mgmt. Sr.is responsible to serve asteam lead for the inpatient concurrent review nursing staffwho 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 a current, active, unrestricted NY RN license and a minimum of 3 years of utilization management and/or managed care experience, which would provide an equivalent background.

-Certification in the American Association of Managed Care Nurses preferred.

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

-Managed care experience highly preferred.

-Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

-Must exhibit leadership skills. This level serves 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.

-May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

-Must be comfortable working with MS Office and web-based applications. Must be able to work with multiple applications simultaneously to gather, input and interpret information.

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.

Job Medical

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: RN Nurse Medical Mgmt Sr. - Team Lead - Inpatient Review Team - Remote - Pine St., NY 136970

Location: NY-New York City

Requisition ID: 136970

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