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Nurse Utilization Management l or ll (Medicare) Group Retiree Solutions

Location: NJ
JobFamily: Medical
Req #: PS60736
Date Posted: Oct 17, 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 care companies and a Fortune Top 50 Company.
Nurse Utilization Management l or ll (Medicare) Group Retirement Solutions (PS59466)
Location: This is a [email protected], telephonic position. Northeast and Central Regions preferred.
Work Hours: 8 hour shift between the hours of 8am and 8pm, Monday – Friday. Some weekends required.
*** Note these positions may be filled at the l or ll levels dependent upon the qualifications and experience of the candidate. ***
The Nurse Medical Management l and ll for Group Retirement Solutions are responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, 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 precertification, 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 members 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.
  • The Level ll Nurse Medical Management may respond to more complex medical issues, serve as a resource to lower-leveled nurses, and may participate in, or lead, intradepartmental teams, projects and initiatives.


Minimum Requirements:
  • Current active unrestricted RN license to practice as a health professional within the scope of practice in the state of residence and ability to obtain multi-state RN license.
  • Requires minimum of 2-3 years (3+ years for the Nurse Medical Management ll) acute care clinical experience, utilization management, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
Preferred Qualifications:
  • Knowledge of medical management process and member benefits for Medicare.
  • Prior managed care (Health Insurance industry) experience.
  • Experience working within Group Retirement Solutions (GRS).
  • Working knowledge ACMP and AUMI.
  • Experience using MS Word and MS Excel.
  • Multi-state RN license.
We offer a range of market-competitive total rewards for those associates scheduled to work greater than 32 hours per week 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 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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