Nurse Medical Mgmt I - Military Veterans

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Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision.u00a0At **MEMBERS ONLY**SIGN UP NOW***., itu2019su00a0a powerful combination, and the foundation upon which weu2019re 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 driveu00a0the future of healthcare.nnThis 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.nNurse Medical Management I/Utilization ReviewnLocation: W@H; GA preferrednSchedule: 8:00-5:00 pm EST; Must be willing to work Sunday-Thursday or Tuesday-Saturday.nRESPONSIBILITIES:nResponsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.nEnsures 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.nWorks with medical directors in interpreting appropriateness of care and accurate claims payment.nMay also manage appeals for services denied.nPrimary duties may include, but are not limited to:nConducts pre-certification, 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.nEnsures member access to medical necessary, quality healthcare in a cost effective setting according to contract.nConsult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.nCollaborates with providers to assess memberu2019s needs for early identification of and proactive planning for discharge planning.nFacilitates 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.nFacilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.nQualifications QUALIFICATIONS:nRequires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and minimum of 2 years acute care clinical experience.u00a0nnWe 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.nnThe health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide u2013 and Anthem approves u2013 a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.nn**MEMBERS ONLY**SIGN UP NOW***. has been named as a Fortune 100 Best Companies to Work Foru00ae, is ranked as one of the 2020 Worldu2019s Most Admired Companies among health insurers by Fortune magazine, and a 2020 Americau2019s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact **** for assistance.

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