Norfolk, VA, or US National
Nurse Medical Mgmt I/II Remote – (PS13930)
Norfolk, Virginia, United States
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 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 or II
Responsible for to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources; or for more complex medical issues Primary duties may include, but are not limited to:
Ensure 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.
Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate appeals payment.
Conducts 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.
Ensure 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, cost effective care throughout the medical management process.
Facilitate member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required.
Facilitate 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.
Train New Hire Associates (Remotely)
Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment auditing
Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, sanctions or other actions)
Assists with development of audit tools, policies and procedures and educational materials.
Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
Analyze and trends performance data, and works with service operations to improve processes and compliance.
Notifies areas of identified problems or providers, recommending modifications to medical policy and on line policy edits.
Communicate and negotiate with providers selected for prepayment review.
Assist investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
Serves as a resource to nurse auditors.
Please Note: This is a remote role and may be filled at either the Nurse Medical Management I or Nurse Medical Management II. Manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position
Nurse Medical Management I
Current active unrestricted RN license practice in state of residence.
2 years clinical RN experience.
2 years of experience with medical review and/or utilization management required.
Managed Care experience preferred.
Experience working with Microsoft Office (Outlook and Word).
Experience using electronic documentation and using multiple compute…
Medical & Health , Case Management , Nursing