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 care companies and a Fortune Top 50 Company.

Nurse Medical Management I (Clinical Rationale Team)
Work schedule: M-F 8:30 am to 5:00 pm EST with a rotation of evening shifts
Location: Remote - within 1-hour commuting distance to any Anthem location

Preferred locations: CA, WA, NV, IN, TN, VA

CRT (Clinical Rationale Team) nurses are responsible for overseeing denial decisions made for the Medicare Advantage enrolled members in accordance and are compliant with applicable criteria, medical policy, member eligibility, benefits, and contracts by working with Anthem Medical Directors and other medical management staff.

Responsibilities include but not limited to:
Daily production of generation of Medicare driven denial letters
Appropriate guideline used to render denial decision
Assuring HIPAA verification
Research and interpretation of member contracts coverage
Working knowledge of CPT, ICD10 codes, Facility-based revenue codes
Verifying codes in PLUTO
Resource and assistance to our MMS (Medical Management Specialist) as needed
Resource for UM partners for guidance for appropriate denial processing

Qualifications

Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state you reside
Requires 3 years of clinical experience
Requires experience with electronic documentation/medical management systems
Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Requires solid skills in Microsoft Office (Excel and Outlook)
Preferred experience working with Medicare and Medicaid
Preferred experience working with ACMP, SharePoint
Preferred experience with CMS (Medicare) and MCG guidelines
Preferred knowledge of Medicare guidelines
Preferred Utilization management experience
Preferred managed care experience

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. An Equal Opportunity Employer/Disability/Veteran.

Anthem, Inc. is ranked as one of Americas Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.