Title: Nurse Medical Mgmt I (PSCCR) - NY, VA, GA - Preferred/Remote - PS12057 COMPANY: Anthem, Inc COMPANY NAICS: Location ZipCode: 40508 Job Description: Nurse Medical Mgmt I (PSCCR) - NY, VA, GA - Preferred/Remote - PS12057 New Location: United States Field: Medical Requisition #: PS12057 Post Date: 5 hours ago Your Talent. Our Vision. At Anthem, Inc., it'sa powerful combination, and the foundation upon which we're creating greater accessto care for our members, greater value for our customers, and greater healthfor our communities. Join us and together we will drive the future of healthcare . This is an exceptional opportunityto do innovative work that means more to you and those we serve at one ofAmerica's leading health benefits companies and a Fortune Top 50 Company. Nurse Medical Mgmt I Preferred locations: NY, GA, VA or anyEast Coast time zone. Remote is an option based on abovelocations. Hours: M - F 8:00 am - 4:30 pm or 8:30 am - 5:00 pm The Nurse Medical Mgmt I is responsible forcollaborating with healthcare providers and members to promote quality memberoutcomes, to optimize member benefits, and to promote effective use ofresources. Primary duties mayinclude, but are not limited to: + Ensures medically appropriate,high quality, cost effective care through assessing the medical necessityof inpatient admissions, outpatient services, focused surgical anddiagnostic procedures, and appropriateness oftreatment setting by utilizing the applicable medical policy and industrystandards, accurately interpreting benefits and managed care products, andsteering members to appropriate providers, programs or communityresources. + Works with medical directors ininterpreting appropriateness of care and accurate claims payment. + Conducts retrospective, out of network appropriateness of treatmentsetting reviews to ensure compliance with applicable criteria, medicalpolicy, and member eligibility, benefits, and contracts. + Ensures member access tomedical necessary, quality healthcare in a cost effective settingaccording to contract. + Consult with clinical reviewersand/or medical directors to ensure medically appropriate, high quality,cost effective care throughout the medical management process. + Facilitates member caretransition through the healthcare continuum and refers treatmentplans/plan of care to clinical reviewers as required and does not issuenon-certifications. + Facilitates accreditation byknowing, understanding, correctly interpreting, and accurately applyingaccrediting and regulatory requirements and standards. Nurse Medical ManagementI + Requires an RN in nursing;2 years of acute care clinical experience; or any combination of educationand experience, which would provide an equivalent background. + Current unrestricted RN licensein applicable state(s) required. + Experience with WGS is a plus. Anthem, Inc. is rankedas one of America's Most Admired Companies among health insurers by Fortunemagazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. Tolearn more about our company and apply, please visit us atcareers.antheminc.com. An EqualOpportunity Employer/Disability/Veteran. Education level: No Grade work Shift: Shift Duration: 3 Driver class: Position count: 1 Orgination method: 11 Employer contact first name: Employer contact last name: Employer contact title: job contact email: Job cantact fax: Job contact phone primary: Job contact phone extension primary: Job contact phone secondary: Job contact phone extension secondary: Location Address 1: Location Address 2: Required LIC certification: Required training: Job status: 1 Office id: KY0099 Onet title: Medical and Health Services Managers