Anthem Nurse Medical Management I, Precertification- Texas -122495 in Texas

Anthem, one of the nation's leading health benefits companies and a Fortune Top 50 company. At Anthem, Inc., we are working together to transform health care with trusted and caring solutions.

Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people’s lives, and to take your career further than you can imagine.

// /Y//our 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 care for our members, greater value for our customers and greater health for our communities. Join us and together we willdrive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

*Location: After successfully completing training, this position has the option to telecommute. *

The Nurse Medical Management 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. 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 pre-certification and care coordination to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

  • Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.

  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

  • 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. //

The Nurse Medical Management I:

  • Requires current active unrestricted RN license in Texas and 2 years acute care clinical experience.

  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

  • Strong computer skills preferred.

/Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at EOE. M/F/Disability/Veteran./

Job Medical

Title: Nurse Medical Management I, Precertification- Texas -122495

Location: Texas

Requisition ID: 122495