Job Description

Description

SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Anthem, Inc., its a powerful combination, and the foundation upon which were 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 benefits companies and a Fortune Top 50 Company.

RN Utilization Review I/II

HOURS: 8:30-5:00 pm; Every Saturday/Sunday and 3 days during the week. There is some flexibility with the 3 days during the week.

LOCATION: Southern CA preferred

RESPONSIBILITIES:

Responsible for collaboration with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.

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 precertification, 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.

- Consults 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

QUALIFICATIONS:

-Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States and 3-5 years acute care clinical experience or case management, utilization

management or managed care experience, which would provide an equivalent background.

- Participation in the American Association of Managed Care Nurses preferred.

- Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

- Prior managed care experience strongly preferred.

- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and

analytical skills.