Anthem Nashville, TN
SHIFT: Day Job
Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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. Nurse – Utilization Review / Home Health (Medicaid) PS54174 Note about Location and Work Hours: This position requires day travel (in the future) throughout your assigned territory in Middle Tennessee. Mileage will be reimbursed. Currently requires virtual meetings during the hours of 8am and 5pm, Monday – Friday, Central Time. Location: This position will allow you to work from your home office. In the future, you will visit members and providers in the field up to 30% of the time, day travel. You must reside in middle Tennessee. The Nurse Medical Management l (Home Health) is responsible for collaborating with healthcare providers primarily 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. Primary duties may include, but are not limited to:
- Conducts pre-certification, continued stay review, care coordination, or discharge planning assessments for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- 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.
- Current active unrestricted RN license to practice as a health professional in the State of Tennessee and 2 years acute care clinical experience.
- Minimum 1 – 2 years home health care or private duty nursing clinical experience.
- Internet Access – Home office.
- Proficient use of computers required.
- Utilization management/review experience within managed care or provider care strongly preferred.
- Case Management, Discharge Planning, and Managed Care experience a plus.
- Ability to assess member needs for outpatient services and support by gathering documentation and interpreting for medical necessity.
- Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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.
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