El Paso, TX, United States
Healthcare, Nursing, Case Management, Manager
Nurse Case Mgr I or II - Remote, Eastern Region - PS18871
Location: United States
Requisition #: PS18871
Post Date: 7 hours ago
Your Talent. Our Vision. At Anthem, Inc., 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 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.
Position may be a Nurse Case Management I or II depending upon level of incumbent's education and relevant skills/ experience. Considering applicants who reside in the Eastern region of the country.
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admission, continued stay review and initial skilled nursing facility and inpatient rehab admission review. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care.
Primary duties may include, but are not limited to:
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 to medical director as required
Correctly interprets and applies appropriate regulatory requirements and standards.
Requires an BS in nursing; 2 years of acute care clinical experience (3 years and 5 years respectively for higher level); or any combination of education and experience, which would provide an equivalent background.
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 and 2 years acute care clinical experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Must have current or previous utilization management experience.
Experience with DSNP and or Medicaid/MLTSS benefits a plus.
Discharge planning, skilled nursing facility (SNF) and/or rehabilitation experience strongly preferred.
Recent experience in GBD Facets preferred.
Knowledge of MCG, Inpatient Surgical (ISC) and General Recovery Guidelines (GRG) strongly preferred.
Knowledge of Medicare Benefit Policy as it applies to SNF and inpatient rehabilitation strongly preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Hours 8AM - 5PM ET with occasional weekends.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 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.
Website : http://www.antheminc.com
The company was formed when WellPoint Health Networks Inc. and Anthem, Inc. merged in 2004 to become the nation's leading health benefits company. The parent company originally assumed the WellPoint, Inc. name at the time of the merger. In December 2014, WellPoint, Inc. changed its corporate name to Anthem, Inc. The Anthem brand is built on a foundation of trust – it’s the name consumers are most familiar with as a trusted health care partner through our affiliated health plans. Anthem, Inc. is one of the largest health benefits companies in the United States. Through its affiliated health plans, Anthem companies deliver a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, Anthem, Inc. is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states.