Anthem RN Nurse Medical Management I/II Utilization Management Atlanta, GA 131221 in Atlanta, Georgia
Your Talent. Our Vision. AtAmerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s the foundation upon which we’re creating greater care for our members, greater value for our customers and greater health for our communities. Join us and together we willdrive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
RN Nurse Medical Management I/II Utilization Management Atlanta, GA 131221
Work Location - Atlanta, GA Amerigroup Office during training; w@home after successful completion of approximately six months of training.
Please note: This position can be filled at the Nurse Medical Management I or II level. Hiring manager will determine level based on the selected applicant's skillset relative to the qualifications listed for this position.
This position is 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 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 Medical Management I: Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Georgia and 2 years acute care clinical experience.
Nurse Medical Management II: Requires current active unrestricted RN license to practice as a health professional in the state of Georgia and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. • Requires strong computer skills with the ability to task between multiple computer systems.
Preferred: • Utilization Management experience strongly preferred. • InterQual experience strongly preferred. • OB/Pediatrics experience. • Discharge Planning experience. • Med-Surg experience. • Participation in the American Association of Managed Care Nurses. • 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 preferred.
/Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran./
Title: RN Nurse Medical Management I/II Utilization Management Atlanta, GA 131221
Requisition ID: 131221