SHIFT: Day Job
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 care companies and a Fortune Top 50 Company.
Nurse Utilization Management l – In-Patient (Medicaid) – PS57281
Location: This is a work@home role but qualified applicants must reside within a 50 mile commute to our Tampa, or Miami, Florida, offices. While the position is remote, occasional meetings and/or training are required in the office.
Work Hours: Monday – Friday, 8am – 5pm or 7am – 4pm with availability to 5pm required.
Primary Duties May Include, But Are Not Limited To
The Nurse Medical Management l for Florida Medicaid is responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources. This role includes some utilization management and in-patient case management responsibilities.
- 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 medically necessary, high-quality healthcare in a cost-effective setting according to contract.
- Consult with clinical reviewers and/or medical directors daily 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.
- Works with medical directors in interpreting appropriateness of care and accurate claims payment.
- May also manage appeals for services denied.
- Current, unrestricted RN license from the state of Florida.
- 3+ years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Experience using Microsoft Word.
- Knowledge of the Utilization Management and/or Utilization Review process (within managed care or provider setting) experience is strongly preferred.
- Prior Medicaid and/or managed care experience is preferred.
- Experience using MS Excel and Outlook strongly 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.