Anthem Nurse Medical Management (RN) - FUTURE OPPORTUNITIES ONLY - 130489 in Rancho Cordova, California
IN ADDITION TO OUR CURRENT OPENINGS, WE CONTINUE TO SOURCE FOR TOP TALENT. *THIS POSTING IS FOR FUTURE OPPORTUNITIES ONLY:*
* * Nurse Medical Management (Job Family) Location: Many Anthem Nurse Medical Management positions allow work at home settings.
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: * 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.
- Requires an active, unrestricted RN license issued by a U.S.
- Requires at least 2 years acute care clinical experience.
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Title: Nurse Medical Management (RN) - FUTURE OPPORTUNITIES ONLY - 130489
Location: california-Rancho Cordova
Requisition ID: 130489