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Posted: Wednesday, December 27, 2017 6:06 AM

*Anthem, Inc.*is 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. ?Please Note: This position may be filled at either the Nurse Medical Management I or Nurse Medical Management II. Manager will determine level based upon the selected applicant?s skillset relative to the qualifications listed for this position.?*__* *_Nurse Medical Management I - Medicare_*Responsible to collaborate with Clinical reviewers and/or medical directors to ensure medically appropriate care through-out the medical management process, accurately interpreting medical policy and industry standards.Primary duties may include, but are not limited to: * Review non-certification of Prior authorization and continued stay reviews for acute inpatients, Acute Rehabs, Acute Long Term Care, and Skilled Nursing Facilities to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. * Review denial rationale language and verify it is appropriate based on the type of denial and verify the grade level is within guidelines. * Facilitates compliance by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.This role will allow you to work remote anywhere within the USYou must reside 80 miles to any Anthem office and be willing to go in if neededThe department is open Monday - Friday 8 AM EST to 11 PM EST, you must be able to work any 8 hour shift within department hours based on needs of the business. *_Nurse Medical Management II - Medicare_*Responsible to collaborate with Clinical reviewers and/or medical directors to ensure medically appropriate care through-out the medical management process, accurately interpreting medical policy and industry standards.Primary duties may include, but are not limited to: * Review non-certification of Prior authorization and continued stay reviews for acute inpatients, Acute Rehabs, Acute Long Term Care, and Skilled Nursing Facilities to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. * Review denial rationale language and verify it is appropriate based on the type of denial and verify the grade level is within guidelines. * Facilitates compliance by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.This role will allow you to work remote anywhere within the USYou must reside 80 miles to any Anthem office and be willing to go in if neededThe department is open Monday - Friday 8 AM EST to 11 PM EST, you must be able to work any 8 hour shift within department hours based on needs of the business. */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 antheminc.com/careers. EOE. M/F/Disability/Veteran.__/* *_Nurse Medical Managment I_**Requires* * Current active unrestricted RN license to practice as a health professional within the scope of practice in state you reside * 3 years utilization management expereince * Acute care RN clinical experience. * Experience with electronic documentation * Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. * Experience working with electronic databases * Microsoft Office (Excel and Outlook * 1 year managed care experience * Knowledge of Medicare Guidelines*/Preferred/* * Experience working with Medicare and Medicaid * Experience working with Facets, ECC, and/or WMDS * Experience with CMS and MGD Guidelines *_Nurse Medical Managment II_**/Requires/* * Current active unrestricted RN license to practice as a health professional within the scope of practice in state you reside * 5 years utilization management expereince * Acute care RN clinical experience. * Experience with electronic documentation * Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. * Experience working with electronic databases * Microsoft Office (Word and Excel) * 2 year of managed care experience * Knowledge of Medicare Guidelines*/Preferred/* * Experience working with Medicare and Medicaid * Experience working with Facets, ECC, and/or WMDS * Experience with CMS and MGD Guidelines **Job** *Medical*Equal Employment Opportunity StatementAnthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity. **Title:** *Nurse Medical Management I & II (Job Family) - Medicare (138666 KT)* **Location:** *california-Modesto* **Requisition ID:** *138666* Company Description:We recently changed our name from WellPoint to Anthem, Inc., the name people know us by best. As our companies continue to take a more active role in helping people access the right health care and programs, going by a name that people know and trust is important.Anthem, Inc. is one of the nation's leading health benefits insurer and a Fortune Top 50 company. At Anthem, Inc., we are working to transform health care with trusted and caring solutions and meaningfully advance affordability and better health outcomes for our health plan members. Nearly 69 million people are served by our affiliated companies including more than 37 million enrolled in our family of health plans. One in nine Americans receives coverage for their medical care through Anthem's affiliated plans.We offer a broad range of medical and specialty products.Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to help drive the future of health care.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 co

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• Location: Modesto

• Post ID: 25452412 modesto
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