Wallingford, CT, United States
Nurse Medical Mgmt Ld - PS 24887 (Any Anthem location or remote)
Location: United States
Requisition #: PS24887
Post Date: 10 hours ago
This job is under review and should not be used without HR Compensation approval. Please note: Associates in this job reporting to designated managers and/or certain states will be paid hourly and be eligible for overtime. Please contact Compensation for confirmation.
Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated 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: continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Conducts precertification, 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. 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. Requires current active unrestricted RN license to practice as a health profesional wihtin the scope of practice in applicable state(s) or territory of the United States and 5 or more years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. Certification 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 required. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Must exhibit leadership skills. The following are level distinctions not required for posting. This level serves as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, may lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Website : http://www.antheminc.com