Anthem RN - Nurse Medical Management I, II Southern California 128562 in Glendale, California

/Your Talent. Our Vision./At Anthem Blue Cross , 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 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 - / /Glendale, Newbury Park, or Woodland Hills, CA/ // /Work Location: This position allows for Telecommuting / Work @ Home with office access to Anthem's Glendale, Newbury Park, or Woodland Hills, CA office./

The shift for this position is Monday -Friday 9 AM-6 PM PST. This is a 40 hour per week position but you may need to work an occasional Saturday and/or Sunday days.

// Please note: This position may be filled at the Nurse Medical Management I, II, or Senior level. The hiring manager will determine the level based upon the selected candidate's experience and skillset.

The Nurse Medical Manager is 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.

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.
  • May also manage appeals for services denied.
  • 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 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.
  • May participate in or lead intradepartmental teams, projects and initiatives.

Nurse Medical Management I:

  • Requires 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • Current unrestricted RN license in CA required.
  • AS/BS in nursing preferred.
  • Prior managed care experience with a focus on Utilization Management or hospital based case management / discharge planning is preferred.

Nurse Medical Management II:

  • Requires AS/BS in nursing
  • 3 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • Current unrestricted RN license in CA required.
  • 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 with a focus on Utilization Management or hospital based case management / discharge planning is preferred.

Other Skills for Both Levels:

  • Knowledge of the Continued stay review process.

  • Excellent computer skills with knowledge of Microsoft applications required.

  • Experience with Electronic medical records is a plus.

  • Must have excellent communication skills (written and verbal) and interpersonal skills.

  • Must be able to work independently and be able to multi-task.

  • Health plan background is preferred.

  • Experience with Medi-cal is preferred.

    • The shift for this position is M-F 9 AM-6 PM PST. This is a 40 hour per week position but you may need to work an occasional Saturday and/or Sunday days.*

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2016 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.

Job Medical

Title: RN - Nurse Medical Management I, II Southern California 128562

Location: CA-Glendale

Other Locations: CA-Woodland Hills, CA-Newbury Park

Requisition ID: 128562