Description
SHIFT: Day Job
SCHEDULE: Full-time
Your Talent. Our Vision. At Simply Healthcare, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities.
We are a Florida licensed health maintenance organization that serves individuals enrolled in Medicaid and/or Medicare programs, 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.
Nurse Medical Mgmt I (Outpatient)
Location: Remote - must reside within 50 miles of the Tampa or Miami Anthem office
Work schedule:  Monday – Friday 9:00am to 6:00pm EST
The Nurse Medical Management I will 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
Qualifications
Minimum requirements:
• Requires current active unrestricted RN license for the state of Florida
• 2 years of utilization management experience.
• Position is work from home, however, must reside within commutable distance to an Anthem office in the State of Florida (Tampa or Miami).
Preferred requirements:
• Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Home Health Durable Medical Equipment experience preferred.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran . Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.