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Anthem, Inc. Nurse Medical Management II or I (Outpatient Utilization Review Nurse) in Memphis, Tennessee

Description

SHIFT: Day Job

SCHEDULE: Full-time

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 care companies and a Fortune Top 50 Company.

Nurse Medical Management II or I (Job Family)* Hours: 8:30 am to 5:30 pm EST (Monday - Friday)

*Please note: This position may be filled at either the Nurse Medical Management II or I. The Hiring Manager will determine level based upon the selected applicant's skillset relative to the qualifications listed for this position. *

Job Description - Nurse Medical Management II

This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.

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.

Job Description - Nurse Medical Management I

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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 - Nurse Medical Management II & I :

  • Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract. (Nurse Medical Management I)

  • 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 accurate ly applying accrediting and regulatory requirements and standards.

Qualifications

Required Qualifications - Nurse Medical Management 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.

    Preferred Qualifications – Nurse Medical Management II

  • 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.

  • Prior managed care experience.

  • Experience using InterQual

    Required Qualifications - Nurse Medical Management I

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Georgia and minimum of 2 years acute care clinical experience.

    Preferred Qualifications – Nurse Medical Management I

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

  • Prior managed care experience.

  • Experience using InterQual

    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: PS60385-Tennessee

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