districtofcolumbia | Registered Nurse in Washington, DC

Registered Nurse

  • Anthem
  • $90,110.00 - 128,790.00 / Year *
  • 715 Gallatin St NW
  • Washington, DC 20011
  • Full-Time
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Nurse Medical Management I or II - Remote - PS18487 **Location:** **United States** **New** **Field:** Medical **Requisition #:** PS18487 **Post Date:** 4 days ago Your Talent. Our Vision. At Anthem Blue Cross, a proud member of the Anthem, Inc. family of companies, 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. **Nurse Medical Management I or II** is responsible to collaborate 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. + 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. This position is being offered at level I or II. The level will be determined by the Hiring Manager based on skills and experience reflected below. + Requires a current active unrestricted RN license to practice as a health professional in the state in which you live. + A minimum of 2 years acute care clinical experience. + Case management, utilization management or managed care experience preferred. + Participation in the American Association of Managed Care Nurses preferred. + Must have knowledge of the 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. + Computer literate: MS Office, web-based applications _Anthem, Inc.is ranked as one of America's Most Admired Companies among health insurers byFortune magazine and is a 2018 Diversity Inc magazine Top 50 Company forDiversity. To learn more about our company and apply, please visit us atcareers.antheminc.com._ _An Equal Opportunity Employer/Disability/Veteran._
Associated topics: bsn, care unit, coronary, domiciliary, intensive, mhb, nurse clinical, psychatric, recovery, surgery

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.