Anthem, Inc. RN Nurse Medical Mgmt Sr (UM) in Louisville, Kentucky
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., 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 Sr. UM nurse position and is remote in the Louisville area. Louisville area residency is required, along with a KY RN license.
HOURS: An 8-hour shift between the hours of 8:00 am and 7:00 pm, M-F
Responsible to serve as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes. 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. Utilizes the applicable medical policy and industry standards, 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 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.
Optimizes member benefits,and promotes effective use of resources for the most complex or elevated medical issues.
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.
This position serves as a team lead and responds to the most complex medical issues.
Current unrestricted RN license from the state of Kentucky is required.
5-7 years acute care clinical experience or case management or utilization management experience, which would provide an equivalent background, is required.
Knowledge of medical management process, and ability to interpret and apply member contracts, member benefits, and managed care products, is required.
2 years prior leadership experience is required.
Certification in the American Association of Managed Care Nurses preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Must be proficient in Microsoft Word, Excel, and Outlook.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 DiversityInc 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.