Anthem, Inc. RN Home Health - Utilization Management Nurse in Nashville, Tennessee
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.
RN Telephonic – Future Home Health – PS40782
Location: Must reside in the Middle Tennessee area within commuting distance to the Davidson, Williamson, Maury and surrounding county areas.
Note: This position requires day travel (in the future) throughout your assigned territory. Mileage will be reimbursed. Currently requires virtual meetings during the hours of 8am and 5pm, Monday – Friday, Central Time.
The Nurse Medical Management l (Home Health) 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. 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. Primary duties may include, but are not limited to:
In the future, will visit members in their homes up to 4 - 5 days per week to conduct pre-certification, continued stay review, care coordination, or discharge planning assessments for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. (Currently meeting with members virtually.)
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.
Current active unrestricted RN license to practice as a health professional in the State of Tennessee.
Minimum 1 - 2 years home health care or private duty nursing clinical experience.
Case Management, Discharge Planning, and Managed Care experience a plus.
Internet Access - Home office.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Ability to assess member needs for home care services by gathering documentation and home visits.
Must reside in one of the counties listed in the Location section of this job posting and be willing and able to work in the field up to 4 - 5 days per week, travelling as much as 2 hours one way. Mileage will be reimbursed.
Proficient use of computers.
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.