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
Location: , MO
Job Family: Medical
Req #: PS47595-Missouri
Date Posted: May 3, 2021
DescriptionSHIFT: Day Job
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 Medical Management I
Locations: KY Preferred; position is [email protected], but must be within a commutable distance to an Anthem office. If located outside of KY,
must hold a KY RN license.
Hours: 8:00 am - 7:00 pm EST with a regular weekend rotation
*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
*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
*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.
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 few.
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.
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 2 years acute care clinical experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical
For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills,
problem-solving skills, facilitation skills, and analytical skills.
Experience with Interqual, Milliman guidelines preferred
Previous UM experience preferred
An Equal Opportunity Employer/Disability/Veteran
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.