What are the responsibilities and job description for the SSB Nurse Medical Mgmt I (contract) position at Anthem?
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 as a contractor at Anthem (via BC Forward) that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
Job Responsibilities
Primary duties may include, but are not limited to: 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.
Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and 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 member's 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
Education & Experience
Requires an AS/BS in nursing; 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required.
Preferred Requirements
Utilization Management experience is highly preferred. Acute inpatient care experience is required. Must be comfortable working in a virtual environment with strong IT/computer skillset to include Excel, Microsoft Outlook, Microsoft Teams. Milliman Care Guideline experience is a plus. Excellent attendance, strong communication skills a plus.
Work Schedule
Monday-Friday 8am-5pm EST. Must reside in IN.
An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.
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