RN Nurse Utilization Management l or II - NY, NJ or CT preferred / East Coast (PS32826)

Anthem in Hialeah, FL

  • Industry: Healthcare - Nursing - Registered Nurse (RN/BSN/ASN)
  • Type: Full Time
  • $64,890.00 - 84,530.00
position filled
RN Nurse Utilization Management l or II - NY, NJ or CT preferred / East Coast (PS32826)
**Location:** **New York City, New York, United States**
**New**
**Requisition #:** PS32826
**Post Date:** 2 days ago
_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.
**Preferred Location:** Tri-State location but will consider other East Coast locations. Qualified candidate must reside within a 2 hour driving distance to an Anthem office
***Position may be filled at the Nurse Medical Management I or II depending upon level of incumbent's education and relevant skills / experience.***
The **Nurse Medical Management l and ll** are 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 admission, continued stay review and initial skilled nursing facility and inpatient rehab admission review. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care. Primary duties may include, but are not limited to:
+ Conducts pre-certification, inpatient, retrospective, out of network and 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 to medical director as required.
+ Correctly interprets and applies appropriate regulatory requirements and standards.
Requires:
+ AS/BS in nursing; 2 years (Nurse Medical Management l) of acute care clinical experience (3 years and 5 years respectively for Nurse Medical Management ll); or any combination of education and experience, which would provide an equivalent background.
+ Requires current, active unrestricted RN license to practice as a health professional in the state where you reside.
+ Must have current or previous utilization management / review experience.
+ In the future, an occasional weekend day will be required with a day off during the week.
+ Experience with DSNP a plus.
+ Discharge planning, skilled nursing facility (SNF) and/or rehabilitation experience strongly preferred.
+ Experience using FACETS preferred.
+ Knowledge of Milliman (MCG) strongly preferred.
+ Knowledge of Medicare Benefit Policy as it applies to SNF and inpatient rehabilitation strongly preferred.
+ Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
**_Anthem, Inc. is ranked as one of America?s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com._** **_An Equal Opportunity Employer/Disability/Veteran._**
Associated topics: ambulatory, coronary, infusion, intensive, nurse clinical, nurse rn, registered nurse, staff nurse, surgery, surgical

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