Nurse Medical Management I/II-Job Family
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 care companies and a Fortune Top 50 Company.
Nurse Medical Management I or Nurse Medical Management II Schedule: Monday-Friday, 6:00 am - 6 pm (EST) Location: Remote-Hybrid
Duties & Responsibilities
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:
Nurse Medical Management I
• 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 w
$55k-93k yearly est.