Anthem, Inc. Nurse Medical Management I/II in Indianapolis, Indiana
SHIFT: Day Job
Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. company, 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.
Nurse Medical Management I/II
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.
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.
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 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.
The following are level distinctions not required for posting.
This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.
Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
Participation in the American Association of Managed Care Nurses preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
Prior managed care experience strongly preferred.
Experience with one of the following is required: Retrospective Review, Concurrent Review, Medical Claims Review, Utilization Review Clinical Research required.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Level II responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.
Position is remote; must live within commutable distance to an Anthem office for occasional meetings, trainings, etc.
Applicable to Colorado Applicants Only
Annual Salary Range*: $66,240- $82,800
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
- The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado . This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. An Equal Opportunity Employer/Disability/Veteran.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 Diversity Inc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.