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Nurse Medical Management I/II

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Job Details
Job Order Number
Company Name
Anthem, Inc
Physical Address

Wilmington, DE 19893
Job Description


SHIFT: Day Job

SCHEDULE: Full-time

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/II

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

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

+ Consults with clinical
reviewers and/or medical directors to ensure medically appropriate, high
quality, cost effective care throughout the medical management

+ 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

+ Facilitates accreditation by
knowing, understanding, correctly interpreting, and accurately applying
accrediting and regulatory requirements and standards.

+ The following are level
distinctions not required for posting.

+ This level responds to more
complex medical issues, serves as resource to lower-leveled nurses, and
may participate in or lead intradepartmental teams, projects and



+ Requires current active
unrestricted RN license to practice as a health professional in applicable
state(s) or territory of the United States and 3-5 years acute care clinical
experience or case management, utilization management or managed care
experience, which would provide an equivalent background.

+ Participation in the American
Association of Managed Care Nurses preferred.

+ Must have knowledge of medical management
process and ability to interpret and apply member contracts, member benefits,
and managed care products.

+ Prior managed care experience strongly

+ Requires strong oral, written and interpersonal
communication skills, problem-solving skills, facilitation skills, and
analytical skills.

+ Level II responds to more complex medical
issues, serves as resource to lower-leveled nurses, and may participate in or
lead intradepartmental teams, projects and initiatives.

+ Position is remote; Must live within commutable distance to an Anthem office for occasional meetings, trainings, etc.

Anthem, Inc. is ranked as one of America’s Most Admired
Companies among health insurers by Fortune magazine and is a 2018 Diversity Inc
magazine Top 50 Company for Diversity. To learn more about our company and
apply, please visit us at An Equal Opportunity


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