Skip to main content

This job has expired

Registered Nurse

Employer
Anthem
Location
Reston, VA
Closing date
Jul 18, 2019

View more

Industry
Insurance
Function
Nurse
Hours
Full Time
Career Level
Experienced (Non-Manager)
Nurse Medical Mgmt Sr / II / I (Job Family) - PS 24099 Any Anthem location or remote **Location:** **United States** **New** **Requisition #:** PS24099 **Post Date:** 3 hours ago _Your Talent. Our Vision._ **At Anthem, Inc.,** it's a powerful combination, and the foundation upon which we're creating greater 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 benefits companies and a Fortune Top 50 Company. Level will be determined by candidates' skills, experience and education **Nurse Medical Management I, II or Sr** Responsible for, review of billed services to optimize member benefits, and to promote effective use of resources; or for more complex medical issues primary duties may include, but are not limited to: Ensure medically appropriate, high quality, cost effective care through medical necessity review of claims billing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable CMS and health plan medical policy and industry standards, accurately interpreting benefits and managed care products. Applies clinical knowledge to ensure medical necessity of billed service. Works with medical directors in interpreting appropriateness of care and accurate payment. Conducts inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensure member benefits are correctly applied to claims payment. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care is reimbursed per the member's contract. . May participate in or lead intradepartmental teams, projects and initiatives. Interacts with service operations as well as other areas of the company relative to claims reviews and their status. Analyze and trends performance data, and works with service operations to improve processes and compliance. Assist investigators by providing medical review expertise to accomplish the detection of fraudulent activities. This position will allow you to work from home. Full-Time position - Monday - Friday Training hours to be determined Work Hours dependent on location (must be able to work an eight hour shift within this time frame) **Requirements** Nurse Medical Management I + Currentactive unrestricted RN license to practice as a health professional withinthe scope of practice in applicable in state you reside in. 2 years clinical RN experience 2 years of experience with medicalrecords claims review. Experience working with MicrosoftOffice (Outlook, Excel, and Word). Experience using electronicdocumentation and using multiple computer screens Requires strong oral, written andinterpersonal communication skills, problem-solving skills, facilitationskills, and analytical skills. Managed care experience preferred. Medicare, Medicaid &/or MedicareSupplement review experience preferred. Coding experience preferred. Experience working in a productionenvironment preferred. Experience with online medicalmanagement and/or claim systems preferred **Requirements** Nurse Medical Management II, Sr + Currentactive unrestricted RN license to practice as a health professional withinthe scope of practice in applicable in state you reside in + 3-5years Medical review and or utilization management or managed careexperience, which would provide an equivalent background. + Experienceworking with Microsoft Office (Outlook, Excel, and Word). + Experienceusing electronic documentation and using multiple computer screens + Musthave knowledge of medical management process and ability to interpret andapply member contracts, member benefits, government regulations andmanaged care products. + Priormanaged care experience strongly preferred. + Requiresstrong oral, written and interpersonal communication skills,problem-solving skills, facilitation skills, and analytical skills. + Experienceworking in a production environment preferred. + Medicare,Medicaid &/or Medicare Supplement review experience required. + Codingexperience preferred + Experiencewith online medical management and/or claim systems required _Anthem, Inc. is ranked as one of America's MostAdmired Companies among health insurers by Fortune magazine and is a 2018Diversity Inc magazine Top 50 Company for Diversity. To learn more about ourcompany and apply, please visit us at careers.antheminc.com. An EqualOpportunity Employer/Disability/Veteran_

Get job alerts

Create a job alert and receive personalized job recommendations straight to your inbox.

Create alert