Anthem In-Patient Concurrent Review Nurse l or ll (RN req'd) NV Medicaid - Remote - 8am - 5pm PST (PS8885) in West Des Moines, Iowa

In-Patient Concurrent Review Nurse l or ll (RN req'd) NV Medicaid - Remote - 8am - 5pm PST (PS8885)


Location: United States

Field: Medical

Requisition #: PS8885

Post Date: Jun 25, 2018

Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals,it’s a powerful combination. It’s 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 may be filled at the Level l or ll upon evaluation of skills and experience.

Location : This position will allow you to work from home. Nevada applicants preferred. Other locations will be considered.

Work Hours : Pacific Coast Time Zone - 8am - 5pm.

The Nurse Medical Management I / ll is 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. Primary duties may include, but are not limited to:

  • Conducts pre-certification, 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.

The Nurse Medical Management I / ll requires:

  • Current, active unrestricted Nevada RN license

  • Minimum 2 (3+ for the Level ll) years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.

  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills - Proficient in using windows-based software programs.


  • Utilization Management experience strongly preferred

  • InterQual experience strongly preferred

  • Managed care and Medicaid

  • The Nurse Medical Management ll responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.

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 please visit us at EOE. M/F/Disability/Veteran .