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Licensed Utilization Review II...

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Job Summary

Company
Anthem
Location
Nashville, TN
Industries
Other/Not Classified
Job Type
Full Time
Employee
Career Level
Experienced (Non-Manager)
Job Reference Code
4298_PS4919

Licensed Utilization Review II (Call Center Nurse)- Nashville, TN- 6/11 Start Date PS4919

About the Job

Description
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.


Nurses for this position must be comfortable working any eight hour shift Monday-Friday between 7am-6pm. Start date is June 11th.
The Licensed Utilization Review Nurse is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines that require the use of clinical thinking/nursing judgment.
Primary duties may include, but are not limited to:
  • Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
  • Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
  • Applies clinical knowledge to work with facilities and providers for care coordination.
  • May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
  • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
  • Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
  • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
Qualifications
  • Requires an LPN, LVN, or RN; 2 years of acute care or utilization review experience; or any combination of education and experience, which would provide an equivalent background.
  • Current active unrestricted license in TN, or multi-state license in the state of residence if state is participatory in the nursing licensure compact.
  • Knowledge of the medical management process preferred.
  • Microsoft Office experience highly preferred.
  • Previous call center experience preferred.
  • 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 and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran

     

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