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Nurse Medical Mgmt I

Location: KY
JobFamily: Medical
Req #: PS57802
Date Posted: Oct 20, 2021

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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 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. 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.

Nurse Medical Management I
Location: [email protected] KY Preferred; however, if located outside KY, must possess a KY or compact RN license.
Hours: Must be available between the hours of 8:00 am-7:00 pm.  Position includes a regular weekend/holiday rotation.

The Nurse Medical Management l position is 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
- 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.

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. 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 Anthem
promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating
applicants for all Anthem positions.



- All levels require current active unrestricted RN license to practice as a health professional within the scope of practice in
the state where you reside and 2 years acute care clinical experience.
- Utilization Management / Review experience required.
- Managed Care / Health Insurance experience preferred.
- MS Word and Excel proficiency 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.