Description:
Description
SHIFT: Day Job
SCHEDULE: Full-time
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.
RN Nurse Utilization Management l (Inpatient) (PS56458)
Location: Residence in the state of Tennessee is required for this position. This is a work@home position but qualified candidates must reside within a reasonable commute to an Anthem office for training and technical needs.
The Nurse Medical Management l for the Tennessee Health Plan is a member of the UM
In-Patient Team and 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 review of initial concurrent authorization requests for skilled nursing, acute in-patient rehabilitation, long term acute care reviews, and acute in-patient 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 member’s 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
- Requires current active unrestricted RN license to practice as a health professional in state of residence and 2 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
- Must reside in the state of Tennessee.
- 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 preferred.
- Strong computer 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.