Anthem, Inc. RN Nurse Utilization Management, Inpatient Review in Jacksonville, North Carolina
SHIFT: Day Job
Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. company, it’s a powerful combination, and 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 healthcare.
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.
LOCATION: This is a remote position servicing our Medicaid members. North Carolina residency is required.
HOURS: Monday through Friday, 8:00 am - 5:00 pm.
The Nurse Medical Management is responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources.
Primary duties may include, but are not limited to:
Conducts pre-certification, 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 medically necessary, high-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.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Current unrestricted RN license from the state of North Carolina.
Requires 2 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
Requires knowledge of the medical management process.
Utilization Review knowledge/experience is preferred.
Prior Medicaid and/or managed care experience is preferred.
You must be competent in Microsoft Word, Excel, and Outlook.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources, to name a few.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.