Skip to main content

It is important that you apply using an email address which is unique to you and not shared with a friend, relative, spouse, or significant other. Our recruiting system uses your email address as your unique identifier. If you apply with a shared email address, your application will overwrite any previous applicant record with the same email address. Additionally, please ensure that you use a valid email address, free from typos, as there are a variety of communications which may be sent to the email address with which you apply

RN Utilization Review I/II

Location: Louisville, KY
Job Family: Medical
Req #: PS41356
Date Posted: Jan 14, 2021

Description

SHIFT: Day Job

SCHEDULE: Full-time

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. 

RN UM I/II Locations: [email protected] but must be commutable to Louisville office
Hours: 8:00am-6:00 pm (Working 8 hours within those)

RESPONSIBILITIES:
 *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 member’s 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. 

Qualifications

QUALIFICATIONS: 
*Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and at least 2 years acute care clinical experience.
 *Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. 
*Experience with prior authorization for D/C planning helpful 
*Proficient with Microsoft office products 
*Prior Managed Care experience preferred, not required
*Holiday and weekend hours required
Share: mail

Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.