RN Medical Management Inpatient Review

Employer
Anthem
Location
Eagan, Minnesota
Posted
May 18, 2018
Closes
Jun 17, 2018
Ref
PS2790
Category
Healthcare
Job Type
Employee
Employment Status
Full Time

Your Talent. Our Vision. At Anthem, Inc., the Government Business Division is focused on serving Medicaid, Medicare and uninsured individuals. Our commitment and focus on government health programs is the foundation upon which we’re creating better care for our members, greater value for our customers and better health for our communities. Join us and together we will drive the future of health care.

 

Join one of the fastest growing businesses in a company with the largest and most successful Medicaid business in the nation. The associate in this position will be supporting members enrolled in the Minnesota Medicaid Program. 

 

RN - Nurse Medical Management I/II/Sr Inpatient Review - Eagan, Minnesota PS2790

Work Location: Eagan, Minnesota

This is an office based position - Monday-Friday 8 a.m. - 5 p.m.

 

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, 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. 

• 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. 

• 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. 

 

 

Level I:

• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Minnesota and 2 years acute care clinical experience. 

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

 

Level II:

• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Minnesota and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. 

• Participation in the American Association of Managed Care Nurses preferred. 

• Must have knowledge of 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. 

 

Senior Level:

• Requires current active  unrestricted RN license to practice as a health professional within the scope of practice in the state of Minnesota and 3 to 5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. 

• Certification in the American Association of Managed Care Nurses preferred. 

• Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. 

• Prior managed care experience required. 

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

• Must exhibit leadership skills. 

 

Key Qualifications:

• Acute Care Experience (i.e. ICU, ER)

• Utilization Management Experience

• Managed Care Experience

• Experience with electronic medical records

• Analytical Skills and Critical Thinking

 

Note: This position may be filled at either the Level I, II or Senior. The manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.

 

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.

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