skip to main content

Important Notice

It appears you are using an older version of your browser. While some functions will be available, Delaware JobLink works best with a modern browser such as the ones provided by:

Please download and install the latest version of the browser of your choice. We apologize for any inconvenience.



Nurse Medical Mgmt I/II or Sr (Job Family) - REMOTE (Multipl

Click the Facebook, Google+ or LinkedIn icons to share this job with your friends or contacts. Click the Twitter icon to tweet this job to your followers. Click the link button to view the URL of the job, which then can be copied and pasted into an e-mail or other document.

Job Details
Job Order Number
JC145727476
Company Name
Anthem
Physical Address

Wilmington, DE 19806
Job Description

Nurse Medical Mgmt I/II or Sr (Job Family) – REMOTE (Multiple Openings) PS25772

Location: United States

New

Requisition #: PS25772

Post Date: 2 days ago

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.


Multiple positions open for Nurse Medical Mgmt I/II or Sr.*

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 schedule between 8am – 8pm EST but may vary for coverage purposes.

Nurse Medical Management I/II/Sr.(Job Family)

Please Note: This position may be filled at the Nurse MedicalManagement I, Nurse Medical Management II, or Nurse Medical Management Seniorlevel. Manager will determine level based upon the selected applicant’sskillset relative to the qualifications listed for this position.

Nurse MedicalManagement I

Responsible to collaborate 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. May also
manage appeals for services denied. 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 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. Collaborates with providers to assess member’s 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.

Nurse MedicalManagement II

Responsible to collaborate with healthcare providers and members to promote
quality member outcomes, to optimize member benefits, and to promote effective
use of resources for more complex medical issues. 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. May also manage appeals for services denied. 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. Consults 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 member’s 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.

Nurse MedicalManagement Sr.

Responsible to serves as team lead for nursing staff who collaborate with
healthcare providers and members to promote quality member outcomes, to
optimize member benefits, and to promote effective use of resources for the
most complex or elevated medical issues.
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. May also
manage appeals for services denied. Primary duties may include, but are not
limited to: continued stay review, care coordination, and discharge planning
for appropriateness of treatment setting reviews to ensure compliance with
applicable criteria, medical policy, and member eligibility, benefits, and
contracts. 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. 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.

Nurse MedicalManagement I:

Requires current active unrestricted RN license to practice as a health
professional within the scope of practice in applicable state(s) or territory
of the United States and 2 years acute care clinical experience. Requires
strong oral, written and interpersonal communication skills, problem-solving
skills, facilitation skills, and analytical skills. For URAC accredited areas
the following applies: Requires strong oral, written and interpersonal communication
skills, problem-solving skills, facilitation skills, and analytical skills.

Nurse MedicalManagement II:


To view full details and how to apply, please login or create a Job Seeker account.