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RN Manager I or II HCMS - Medi...

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Job Summary

Company
Anthem
Location
Eagan, MN
Industries
Other/Not Classified
Job Type
Full Time
Employee
Career Level
Experienced (Non-Manager)
Job Reference Code
4298_PS2987

RN Manager I or II HCMS - Medicaid Outpatient Utilization Management (RN Preferred; will also con...

About the Job

Description
Your Talent. Our Vision. At Anthem, Inc., the Government Business Division is focused on serving Medicaid, Medicare and uninsured individuals. Our commitment and focus on government health programs is the foundation upon which we're creating better care for our members, greater value for our customers and better health for our communities. Join us and together we will drive the future of health care.
Join one of the fastest growing businesses in a company with the largest and most successful Medicaid business in the nation. The associate in this position will be supporting members enrolled in the Minnesota Medicaid Program.

RN Manager I or II HCMS - Outpatient Utilization Management (Job Family) Eagan, MN PS2987

Work Location: Eagan, Minnesota
This is an office based position - Monday-Friday 8 a.m. - 5 p.m.

Responsible for managing a team of physical and/or behavioral health practitioners responsible for coordinating member service, utilization, access, care management and/or concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services for one or more member product populations of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members.

Primary duties may include, but are not limited to:

* Manages and oversees team responsible in case finding and coordinating cases that involve comorbid conditions.
* Coordinates service delivery to include member assessment of physical and psychological factors.
* Partners with providers to establish short and long term goals that meet the member's needs, functional abilities, and referral sources requirements.
* Identifies members with potential for high risk complications.
* Reviews benefit systems and cost benefit analysis.
* Evaluates medical, mental health and substance abuse service for cost containment.
* Supports program compliance and assists in identifying opportunities to improve the customer service and quality outcomes.
* Supports quality initiatives and activities, including adherence to National Committee for Quality Assurance (NCQA) standards and HEDIS reporting.
* Hires, trains, coaches, counsels, and evaluates performance of direct reports.



Level II:
Responsible for managing a team of physical and/or behavioral health practitioners in the development, implementation, and coordination of a comprehensive integrated Medical Management program designed to manage health outcomes in a highly complex member populations with varying degrees of medical complexity and acuity. Participates in case and/or utilization management execution/decision making for managed member populations.

Primary duties may include, but are not limited to:
* Engages in the development and implementation of integrated medical management programs across the different member population types covered by the health plan.
* Ensures continued compliance with specific medical management standards.
* Engages in the development process for medical and clinical management policy, procedures, and strategies.
* Evaluates medical, mental health, and substance abuse services for cost containment, to include complex/specialized member populations.
* Ensures program deliverables and compliance by monitoring established goals and implementing improvement strategies.
* Takes the lead within assigned area on ensuring the unit is positioned and prepared to execute on quality initiatives and activities including clinical indicators reporting, focus studies, HEDIS reporting and adherence to National Committee for Quality Assurance (NCQA) standards.
* Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Qualifications
Level I:
* Requires a BA/BS; 5 years of experience in Health Care Management; or any combination of education and experience, which would provide an equivalent background.
* Current active unrestricted RN, PA, LSW, LCSW, LPC, LMHC or other accepted license (as allowed by applicable state laws); and any other state or federal requirements that may apply is required.
* MSN, MPH, MPA, MSW or MBA with Health Care Concentration preferred.
* Certified Case Manager Certification preferred.

Level II:
* Requires a BA/BS in a related Health/Nursing field; 6 years of experience as aligned to appropriate license, including 3 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
* Current active unrestricted RN, LCSW, LPC, LMHC or other accepted license (as allowed by applicable state laws); and any other state or federal requirements that may apply is required.
* Masters in related Health/Nursing field preferred.
* Certified Case Manager Certification preferred.

Key Qualifications:
* Processional Licensure in the state of Minnesota required; RN licensure Preferred
* Experience with Outpatient Nursing (i.e. Durable Medical Equipment, Home Care, Physical Therapy, Occupational Therapy, Speech Therapy)
* Utilization Management Experience
* Managed Care Experience
* Experience with electronic medical records
* Ability to multi-task and switch gears quickly and comfortable working in a productivity environment with a work queue
* Analytical Skills and Critical Thinking
* Leadership experience
* Project Management skills
* MS Office - especially MS Excel for reporting
* Excellent oral and written communication skills
* Public speaking or training experience a plus

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 antheminc.com/careers. EOE. M/F/Disability/Veteran.

 

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