Anthem Medicare Nurse Medical Management II (Acute) Central Region (133545) in Hamilton, Indiana
/Your Talent. Our Vision./At Anthem Blue Cross and Blue Shield, a proud member of the Anthem, Inc. family of companies,* it’s a powerful combination, and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we willdrive the future of health care*. This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Nurse Medical Management II
Responsible for collaborating 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 for the Ohio Medicare Advantage. 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. * 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 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. * Will be cross-trained in utilization management and case management. * May participate in or lead intradepartmental teams, projects and initiatives.
Requires 2 years of acute care clinical experience (3 years for level II); or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in residing state. AS/BS in nursing preferred.
Preferred Medicare Advantage knowledge and experience (current experience preferred) Prior or current utilization review/utilization management experience Facets knowledge and experience
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Title: Medicare Nurse Medical Management II (Acute) Central Region (133545)
Requisition ID: 133545