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RN Nurse Medical Mgmt I (Utili...

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Job Summary

Company
Anthem
Location
Buffalo, NY
Industries
Other/Not Classified
Job Type
Full Time
Employee
Career Level
Experienced (Non-Manager)
Job Reference Code
4298_PS5125

RN Nurse Medical Mgmt I (Utilization Management) - Remote - Buffalo, NY - PS5125

About the Job

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 benefits companies and a Fortune Top 50 Company.

This Nurse Medical Mgmt. I position focuses on Utilization Management for our Medicaid members in the WNY region of the state. You will receive the training and equipment to work from a home office, but should be within commuting distance to our Buffalo, NY office on Genesee St. for training and occasional meetings. You must have a high speed internet connection.

The Nurse Med. Mgmt. I is 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.

Qualifications

BSN preferred. Requires a current, active, unrestricted RN license in NY and a minimum of 2 years acute care clinical experience, or any combination of education and experience that would provide an equivalent background.

-Utilization review experience required.

-Knowledge of Facets preferred.

-MS Office (Word, Outlook, Excel) - You must be comfortable working on a computer with web based applications. You will be updating excel worksheets and reviewing and inputting information on multiple screens. Lack of computer skills could affect your ability to be successful in this position.

-Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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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