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Summary: The Nurse Medical Management l, ll, and Sr. positions 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 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.
Nurse Medical Manager Level 1 / Level 2: This position will allow you to work remotely as long as you reside within a reasonable commuting distance to an Anthem office. *Weekends are required plus 3 days during the week.
- 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 member’s 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 ll and Sr.
The level ll Nurse Medical Management responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in intradepartmental teams, projects and initiatives.
The Sr. Nurse Medical Management responds to the most complex medical issues, ensures consistency in benefit application, may participate in intradepartmental teams, projects, initiatives, process improvement activities, and requires previous managed care experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.
- All levels require current active unrestricted RN license to practice as a health professional within the scope of practice in the state where you reside and 2 years acute care clinical experience.
- Utilization Management / Review experience required.
- Managed Care / Health Insurance experience preferred.
- MS Word and Excel proficiency preferred.
The Level ll and Sr Levels in addition to the above require:
- 3 – 5 years of acute care clinical experience or case management, utilization management or managed care experience, or any combination which would provide an equivalent background.
- Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Health, dental, vision, life, disability, retirement, and more is available
Eligible CareerGig freelancers get access to affordable guaranteed-issue health, dental, vision, life, and disability insurance, as well as other benefits such as retirement and more.
What's more, CareerGig contributes a portion of our fees towards your benefits. You can learn more about CareerGig benefits here.
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CareerGig (Digics, Inc.) is an equal opportunity employer.