Therapy Reviewer (myNEXUS)

at Anthem, Inc in Wilmington, Delaware, United States

Job Description


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, 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. myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness. Job Summary: Perform pre-certification, certification and/or authorization activities for all requested Home Health Services included as contracted services that meet eligibility and benefits coverage. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. When necessary, requests additional clinical information from member’s care providers. Refers requests that do not meet coverage guidelines criteria to myNEXUS Medical Director for a Level III Review. The case management component of the UM program is designed to identify and monitor delivery of home health services in an efficient manner, responding to a member’s total health needs and ensure the highest quality of continuity of care. Duties/Responsibilities

+ Conducts case review with primary focus on therapy utilization to assure proper use of services relative to medical necessity, level of skill required for patient, type of therapy services needed, and the timing of therapy services rendered.

+ In meeting the demands of therapy case review, must also formulate different ways of managing member care to meet positive outcomes in the most cost effective manner.

+ Educates, plans, direct and supports care management team, while working with the VP, Therapy Innovations, and the Senior Medical Director to insure continuity across all levels.

Education and Experience:

+ Licensed Physical Therapist or Physical Therapy Assistant; minimum of 5 years of experience in a variety of health care settings

+ Home health experience preferred

+ Current state license in the state where membership lives

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions. REQNUMBER: PS49981 To view full details and how to apply, please login or create a Job Seeker account
How to Apply Copy Link

Job Posting: JC182947130

Posted On: May 06, 2021

Updated On: Sep 16, 2021