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Job Family: Business Support
Req #: PS51661
Date Posted: Jun 23, 2021
DescriptionSHIFT: Day Job
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination. It’s 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 health care.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.
Perform post decision clinical and nonclinical activities for all requested Home Health Services included as contracted services that meet eligibility and benefits coverage. Responsible for Peer to Peer request processing, post review consultations with members and their representatives, provider-initiated communication regarding adverse medical determinations, scheduling of peer to peer reviews, and sending written notifications to health plan members, ordering physicians, and home health care providers. When necessary, requests additional clinical information from member’s care providers.
• Identifies themselves by name, title and company name on all telephone calls. Provides upon request information on specific UM requirements and procedures.
• Research of adverse determinations and preparation of research findings for physician Peer to Peer review.
• Answers the telephone and provider and member requests in a timely and polite manner.
• Is responsible for compliance with regulatory turnaround times in relation to notification of intent to deny, Peer to Peer reviews, and required written notifications. Proactively escalates those cases that are at risk of not being completed within department policy.
• Adheres to clinical review scripts, criteria and department protocols in all case reviews.
• Clearly and accurately communicates post review information and research outcomes interdepartmentally and externally.
• Communicates clearly and professionally with ordering physicians and home care agencies to obtain information necessary to complete a Peer to Peer review and schedules this review between our Medical Director and the ordering physician.
• Educates home care agencies and physicians on the process for Peer to Peer review.
• Documents all member and provider communications appropriately and according to departmental policies.
• Maintains and respects confidentiality of member/physician/personnel information
• Documents all member and provider complaints appropriately and in compliance with departmental policy and escalates complaints to department supervisor for further action and resolution.
• Responsible for accurate review and entry of authorization data into computerized database. Ensures accuracy of data and follows departmental policy regarding the documentation of activities.
• Performs all responsibilities in an environment that optimizes member safety, protects their health information, and ensures timely notification of review outcomes.
• Knowledgeable of current departmental policy, Medicare and Medicaid requirements, necessity and justification requirements.
• Maintains a good rapport with physicians, private insurance companies and government agencies.
• Maintains a good working relationship with peers and interdepartmentally.
• Consults other departments as appropriate to ensure accurate and complete information is obtained for medical review determinations.
• Responds to all requests for information from physicians, home care agencies, and members and/or their representatives in a timely and professional manner.
• Accepts additional assignments willingly.
• Adheres to dress code, appearance is neat and clean.
• Completes annual education and licensure requirements.
• Maintains member confidentiality at all times.
• Reports to work on time and as scheduled, completes work within designated time.
• Follows all company policies related to time records.
• Completes in-services in a timely fashion.
• Attends annual review and department in-services, as scheduled.
• Attends at staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.
• Represents the organization in a positive and professional manner.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.
Education and Experience:
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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.
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