SHIFT: Day Job
Your Talent. Our Vision. At UniCare, a subsidiary of 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.
RN Utilization Management – Medicaid Outpatient (PS55376)
Location: This position will allow you to work from your home office. You must reside in the state of West Virginia.
Work Hours: Regular business hours
The Nurse Medical Management l position for Unicare (Medicaid West Virginia) is responsible for collaborating 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 outpatient services 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 or programs. Works with medical directors in interpreting appropriateness of care. Primary duties may include, but are not limited to:
- Conducts pre-certification 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.
- 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.
- Current active unrestricted RN license to practice as a health professional within the scope of practice in the state of West Virginia.
- Must reside in the state of West Virginia.
- 2 or more years of acute care clinical experience.
- Experience using multiple computer programs simultaneously.
- Knowledge of substance abuse disorders.
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.
Clipped from: https://anthemcareers.ttcportals.com/jobs/7267461-nurse-medical-management-l-telephonic-medicaid-outpatient?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic