RN Nurse Utilization Management, Inpatient Review
Company: Anthem, Inc.
Posted on: June 8, 2021
SHIFT: Day Job
Your Talent. Our Vision. At Healthy Blue, a strategic alliance
of Blue Cross NC and Amerigroup, an Anthem Inc. company, it's a
powerful combination, and the foundation upon which we're 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 drive the future of healthcare.
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.
LOCATION: This is a remote position servicing our Medicaid
members. North Carolina residency is required.
HOURS: Monday through Friday, 8:00 am - 5:00 pm.
The Nurse Medical Management is responsible to collaborate with
healthcare providers and members to promote quality member
outcomes, optimize member benefits, and promote effective use of
resources. Accurately interprets benefits and managed care
products, and steers members to appropriate providers, programs, or
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
- Ensures member access to medically necessary, high-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
- 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.
- Works with medical directors in interpreting appropriateness of
care and accurate claims payment.
- May also manage appeals for services denied.
- Current unrestricted RN license from the state of North
- Requires 2 years acute care clinical experience; or any
combination of education and experience, which would provide an
- Requires knowledge of the medical management process.
- Utilization Review knowledge/experience is preferred.
- Prior Medicaid and/or managed care experience is
- You must be competent in Microsoft Word, Excel, and
We 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
Anthem, Inc. is ranked as one of America's Most Admired
Companies among health insurers by Fortune magazine and has been
named a 2019 Best Employers for Diversity by Forbes. To learn more
about our company and apply, please visit us at
careers.antheminc.com. An Equal Opportunity
Employer/Disability/Veteran. Anthem promotes the delivery of
services in a culturally competent manner and considers cultural
competency when evaluating applicants for all Anthem positions.
Keywords: Anthem, Inc., Greenville , RN Nurse Utilization Management, Inpatient Review, Other , Goldsboro, North Carolina
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