Anthem RN Nurse Medical Mgmt I/II, Utilization Review - Richmond office, Virginia PS4036 in Sweetwater, Texas

/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.

Location: This position begins in our Richmond VA office, for an undetermined period of time, and then will become a Work @ Home opportunity.

In this position, you are responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

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.

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Virginia and 3 years acute care clinical experience.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Prior managed care experience preferred.
  • Inpatient and outpatient utilization management experience preferred.
  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
  • Computer skills: MS Word, Outlook, Excel required. Must be confident and comfortable working on computers using multiple screens and web-based programs.
  • Ability to commute daily to our Richmond, VA office.

/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 and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran./

Job Medical

Equal Employment Opportunity Statement Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.

Title: RN Nurse Medical Mgmt I/II, Utilization Review - Richmond office, Virginia PS4036

Location: texas-Sweetwater

Requisition ID: PS4036