Nurse Medical Management I / II Details

Nurse Medical Management I / II

Anthem - Portland, ME

Employment Type : Full-Time

Description

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.

*** Note: This position may be filled at the Nurse Medical Management l, ll level depending on candidates’ skills, experience, and education. ***

Location: WAH. Must reside within 2 hours of an Anthem location.

Work Hours: Mon.-Fri. 8:30am-5:00pm; weekend rotation (one weekend a month); holidays

The Nurse Medical Management l, ll levels are responsible to collaborate telephonically with healthcare providers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:

• Knowledge of pre-certification and continued stay reviews
• 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.
• Ensures member access to medically necessary quality healthcare in a cost effective setting according to member contract.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, care throughout the medical management process.
• Assesses the medical necessity of outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting.
• Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products.
• Steers members to appropriate providers, programs or community resources.
• Collaborates with providers to assess members' needs for early identification of and proactive 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.
• Works with medical directors in interpreting appropriateness of care
• May also manage appeals for services denied.

Nurse Medical Management II responds to more complex medical issues, serves as resource to lower level nurses, and may participate in or lead intradepartmental teams, projects and initiatives.

Qualifications

Minimum Requirements:

• Current, active, unrestricted RN license from the state of residence.
• Minimum 2 - 3 years acute care clinical experience is required. (3 – 5 years for the Level ll roles required)

Preferred Qualifications:

• Utilization Management or Utilization Review experience is required.
• Proficient using MS Word and MS Excel.

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.