Anthem, Inc. RN Utilization Review I-Outpatient in Andover, Massachusetts
SHIFT: Day Job
Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving
Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.
Outpatient Nurse Medical Management I
Location: W@H but must have NV license and willing to work 8-5:00 PST
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 outpatient services, 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.
Primary duties may include, but are not limited to:
- Conducts pre-certification, 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 medically necessary, quality healthcare in a cost effective setting according to contract.
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, refers treatment plans/plan of care to clinical
reviewers as required, and does not issue medical necessity non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Requires current active unrestricted license to practice as a health professional within the scope of practice in the State
of Nevada and 2 years acute care clinical experience.
Position is remote.
Utilization Management and/or comparison to medical criteria experience preferred.
Strong computer system proficiency to include Microsoft Office Suite.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and
- Must be willing to work Pacific time zone hours 8:00AM-5:00PM
-Managed Care experience preferred but not required.
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