Nurse Medical Mgmt Ld - PS 25774 (Any Anthem location or remote)**Location:** **California, United States****Requisition #:** PS25774**Post Date:** Aug 02, 2019_Your Talent. Our Vision._ **At Anthem, Inc.,** its apowerful combination, and the foundation upon which were creating greater carefor our members, greater value for our customers, and greater health for ourcommunities. Join us and together we will **drive the future of health care** .This is an exceptional opportunity to do innovative work thatmeans more to you and those we serve at one of America's leading healthbenefits companies and a Fortune Top 50 Company.**Multiple positions open for NurseMedical Management Lead****Preferred Location** s: Remote but Residents in Western US are a plus!**Other Locations:** Remote, anywhere in the US. Must be able to work a schedulebetween 8am 8pm EST but may vary for coverage purposesResponsible to serves as team leadfor nursing staff who collaborate with healthcare providers and members topromote quality member outcomes, to optimize member benefits, and to promoteeffective use of resources for the most complex or elevated medicalissues.Ensures medically appropriate,high quality, cost effective care through assessing the medical necessity ofinpatient admissions, outpatient services, focused surgical and diagnosticprocedures, out of network services, and appropriateness of treatment settingby utilizing the applicable medical policy and industry standards, accuratelyinterpreting benefits and managed care products, and steering members toappropriate providers, programs or community resources. Works with medicaldirectors in interpreting appropriateness of care and accurate claims payment.May also manage appeals for services denied.Primary duties may include, but arenot limited to:+ Continued stay review, care coordination, and dischargeplanning for appropriateness of treatment setting reviews to ensurecompliance with applicable criteria, medical policy, and membereligibility, benefits, and contracts.+ Conducts precertification, continued stay review, carecoordination, or discharge planning for appropriateness of treatmentsetting reviews to ensure compliance with applicable criteria, medicalpolicy, and member eligibility, benefits, and contracts.+ Ensures member access to medical necessary, qualityhealthcare in a cost effective setting according to contract.+ Consult with clinical reviewers and/or medicaldirectors to ensure medically appropriate, high quality, cost effectivecare throughout the medical management process.+ Collaborates with providers to assess members needs forearly identification of and proactive planning for discharge planning.+ Facilitates member care transition through thehealthcare continuum and refers treatment plans/plan of care to clinicalreviewers as required and does not issue non-certifications.+ Facilitates accreditation by knowing, understanding,correctly interpreting, and accurately applying accrediting and regulatoryrequirements and standards.+ Requires current active unrestricted RN license topractice as a health professional within the scope of practice inapplicable state(s) or territory of the United States and 5 or more yearsacute care clinical experience or case management, utilization managementor managed care experience, which would provide an equivalent background.+ Certification in the American Association of ManagedCare Nurses preferred.+ Must have knowledge of medical management process andability to interpret and apply member contracts, member benefits, andmanaged care products.+ Prior managed care experience required.+ Requires strong oral, written and interpersonalcommunication skills, problem-solving skills, facilitation skills, andanalytical skills. Must exhibit leadership skills.+ This level serves as a team lead and responds to themost complex medical issues, ensures consistency in benefit application,may lead cross-functional teams, projects, initiatives, process improvementactivities, and requires previous managed care experience.+ May serve as departmental liaison to other areas of thebusiness unit or as representative on enterprise initiatives.+ Training experience is a plus+ Formal leadership experience is desiredFor URAC accreditedareas the following applies:+ Requires strong oral, written and interpersonalcommunication skills, problem-solving skills, facilitation skills, andanalytical skills._Anthem, Inc.is ranked as one of Americas Most Admired Companies among health insurers byFortune magazine and is a 2018 Diversity Inc magazine Top 50 Company forDiversity. To learn more about our company and apply, please visit us atcareers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran._ Associated topics: licensed, licensed vocational nurse, lvn lpn, mtp, nurse i, nurse ii, nurse iv, pediatrics, practical nurse, vocational nurse
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.