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Posted: Monday, September 4, 2017 10:44 AM

/ 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. Nurse Medical Management I/II/ Sr *Location*: Any Anthem Location; Work at home is an option The selected candidate will be hired at the level that best reflects their experience*. *Nurse Medical Management I* 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 II* 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: * Conducts precertification, 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 * 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 Sr.* Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated 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: * Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts * Conducts precertification, 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 applicable state(s) or territory of the United States and 2 years acute care clinical experience. * Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills * Requires at least 2 years of experience working as an RN * Experience working in utilization review or acute hospital care required * Discharge planning and/or SNF (Skilled Nursing Facility) experience a plus * Recent working knowledge and experience in Facets and/or MCG guidelines helpful * Knowledge of CMS Medicare requirements preferred *Nurse Medical Management II* Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. * Participation in the American Association of Managed Care Nurses preferred * 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 * Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills * Requires at least 2 years of experience working as an RN * Experience working in utilization review or acute hospital care required * Discharge planning and/or SNF (Skilled Nursing Facility) experience a plus * Recent working knowledge and experience in Facets and/or MCG guidelines helpful * Knowledge of CMS Medicare requirements preferred *Nurse Medical Management Sr.* Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. * Certification in the American Association of Managed Care Nurses preferred * 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 required * Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills * Must exhibit leadership skills * Requires at least 2 years of experience working as an RN * Experience working in utilization review or acute hospital care required * Discharge planning and/or SNF (Skilled Nursing Facility) experience a plus * Recent working knowledge and experience in Facets and/or MCG guidelines helpful * Knowledge of CMS Medicare requirements 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 and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. / **Job** *Medical* **Title:** *Nurse Medical Management I/II/Sr. (Any Anthem Location) (133967)* **Location:** *texas-Abilene* **Requisition ID:** *133967* Company Description:We recently changed our name from WellPoint to Anthem, Inc., the name people know us by best. As our companies continue to take a more active role in helping people access the right health care and programs, going by a name that people know and trust is important.Anthem, Inc. is one of the nation's leading health benefits insurer and a Fortune Top 50 company. At Anthem, Inc., we are working to transform health care with trusted and caring solutions and meaningfully advance affordability and better health outcomes for our health plan members. Nearly 69 million people are served by our affiliated companies including more than 37 million enrolled in our family of health plans. One in nine Americans receives coverage for their medical care through Anthem's affiliated plans.We offer a broad range of medical and specialty products.Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to help drive the future of health care.Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our co

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• Location: Abilene

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