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Anthem, Inc Nurse Medical Mgmt I in West Des Moines, Iowa

Nurse Medical Mgmt I

Location: United States

Requisition #: PS29734

Post Date: Nov 01, 2019

Your Talent. Our Vision. At Anthem, Inc., 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 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 benefits companies and a Fortune Top 50 Company.

As a NurseMedical Management associate, you will responsible for collaborating with healthcare providers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

Location: The selected candidate will work in the Tampa Florida office,

Address: 4200 W. Cypress St. Tampa Florida

Hours during training(about 3 weeks): Monday through Friday, 8am to 5pm

Standard hours aftertraining: Monday through Friday 9am to 6pm

Primary duties may include, but are not limited to:

  • Ensures medically appropriate, high quality, costeffective care through assessing the medical necessity of outpatientservices, focused surgical and diagnostic procedures, out of networkservices, home health and durable medical equipment requests and appropriatenessof treatment setting by utilizing the applicable medical policy andindustry standards, accurately interpreting benefits and managed careproducts, and steering members to appropriate providers, programs orcommunity resources.

  • Applies clinical knowledge to work with facilities andproviders for care coordination.

  • Works with medical directors in interpretingappropriateness of care and accurate claims payment.

  • May also manage appeals for services denied.

  • Conducts pre-certification, inpatient, retrospective,out of network and appropriateness of treatment setting reviews to ensurecompliance with applicable criteria, medical policy, and membereligibility, benefits, and contracts. Ensures member access to medicalnecessary, quality healthcare in a cost effective setting according tocontract.

  • Consult with clinical reviewers and/or medicaldirectors to ensure medically appropriate, high quality, cost effectivecare throughout the medical management process.

  • Collaborates with providers to assess members` needsfor early identification of and proactive planning for dischargeplanning.

  • Facilitates member care transition through thehealthcare continuum and refers treatment plans/plan of care to clinicalreviewers as required and does not issue non-certifications.

  • Facilitates accreditation by knowing, understanding,correctly interpreting, and accurately applying accrediting and regulatoryrequirements and standards.

  • Current unrestricted FL RN license is required

  • Requires 2 years of acute care clinical experience toinclude utilization mgmt. review and prior authorization experience

  • AS/BS in nursing preferred

  • Proficiency in Microsoft office, e.g., Excel andWord

Anthem, Inc. is ranked as one ofAmerica’s Most Admired Companies among health insurers by Fortune magazine andis a 2018 Diversity Inc magazine Top 50 Company for Diversity. To learn moreabout our company and apply, please visit us at careers.antheminc.com. An EqualOpportunity Employer/Disability/Veteran.

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