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RN Nurse Medical Mgmt, UM (Te...


Job Summary

Clay, KY
Other/Not Classified
Job Type
Full Time
Career Level
Experienced (Non-Manager)
Job Reference Code

RN Nurse Medical Mgmt, UM (Telecommute) KY-IN-TN-MO-GA-WI Residency PS4534

About the Job

Your Talent. Our Vision. At Anthem Blue Cross, a proud member of the Anthem, Inc. family of companies, 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.

Location: This is a remote, work from home opportunity, and you will cover the following states within our Central Region: KY, IN, TN, MO, GA, WI. You must reside in one of these states.

We have an immediate need for a UM Nurse Medical Management I/II (RN). In this position, you are responsible to collaborate with healthcare providers and members 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:

  • Conducts pre-certification, continued stay review, 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, cost effective care throughout the medical management process.
  • 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.

  • A high speed internet connection is required. A Wi-Fi hot spot or satellite connection is not acceptable.
  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States;
  • Minimum of 3 plus years acute care clinical experience is required.
  • Previous Utilization Management experience is required.
  • Managed Care experience is preferred.
  • Requires strong oral, written and interpersonal communication, problem-solving, facilitation and analytical skills.
  • Knowledge of Facets a plus.
  • Requires the ability to maintain Eastern Standard/Daylight work hours, regardless of the time one in which you reside.

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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