Nurse Medical Mgmt II (Job Family - Woodland Hills, CA - 73991SY
CA , Woodland Hills
Job Post Date:
Anthem Blue Crossis a proud member of the WellPoint family of companies and is one of California’s oldest and largest health insurers. At Anthem, we are working together to transform health care with trusted and caring solutions.
Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people’s lives, and to take your career further than you can imagine.
Responsible for collaborating 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. Primary duties may include, but are not limited to: 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. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. 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 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. May participate in or lead intradepartmental teams, projects and initiatives.
Requires AS/BS in nursing; 3-5 years acute care clinical experience along with case management and 2-5 years UM experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted California RN license is required. 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 preferred. Must have the ability to communicate effectively with medical groups. Requires strong oral, written and interpersonal communication sills, problem-solving skills, facilitation skills, and analytical skills. Basic PC skills, work, excel, outlook required.
As business needs may require, these positions may require additional state licenses now or in the future. Inability or unwillingness to obtain these required licenses may result in either re-assignment (if available) or termination. Obtaining required licenses is a requirement for continued employment.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us atwww.wellpoint.com/careers. EOE. M/F/D/V.
Once an offer is accepted, all external applicants are subject to a background investigation
and if appropriate, drug testing. Offers of employment shall be contingent upon
passing both the background investigation and drug testing (if required).
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