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Anthem, Inc. Nurse Medical Mgmt II / Sr- Job Family in La Mirada, California

Description

SHIFT: Day Job

SCHEDULE: Full-time

Y our 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 care companies and a Fortune Top 50 Company.

This position can be filled at Nurse Medical Mgmt II level or Nurse Medical Mgmt Sr level. The hiring manager will determine the level, based on the candidate’s experience and background.

Schedule: Monday-Friday 11:00am-8:00pm EST

Location: Remote

Nurse Medical Mgmt II level:

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex 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:

  • 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.

  • Consults 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 member’s 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.

    Nurse Medical Mgmt Sr level:

    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.

  • This level serves as a team lead and responds for 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.

Qualifications

Nurse Medical Mgmt II:

  • Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States.

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

  • Participation in the American Association of Managed Care Nurses preferred. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.

  • Prior managed care experience strongly preferred.

  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

Nurse Medical Mgmt Sr:

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.

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

  • Prior managed care experience required.

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

  • Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.

  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

  • Leadership skills strongly preferred

  • Medicare experience a plus.

Applicable to Colorado Applicants Only:

Annual Salary Range*: $66,240 - $88,800

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

  • The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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: PS60753-California

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