Anthem, Inc. Licensed Utilization Review II - PS37234 in Indianapolis, Indiana
SHIFT: Day Job
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 healthcare.
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.
LOCATION: This is a work at home role. However, candidates must reside within 60 miles of an Anthem office.
HOURS: Monday thru Friday, 10:30 am - 7:00 pm EST; some OT may be required. Shifts may vary due to business needs.
The Licensed Utilization Review Nurse is a telephonic position. In this position, you are 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.
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.
Current, active unrestricted LPN, LVN or RN license required.
3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background, is required.
2 years of utilization review experience is preferred.
Experience in a hospital or urgent care setting is preferred.
Medicaid/Medicare and/or Managed Care experience is preferred.
Must be willing and able to work Mon – Fri, 10:30 am to 7:00 pm EST; some occasional OT may be required.
6 months of experience, working on the Anthem Medicare Authorization Team, highly preferred.
You must be competent in Microsoft Word, Excel, and Outlook.
Ability to multi-task and toggle between multiple programs required.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2019 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit' us at antheminc.com/careers.