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Wound Care UM RN (myNEXUS) CWCN CWOCN CWS - Remote

Location: TN
JobFamily: Medical
Req #: PS67102
Date Posted: Feb 17, 2022

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SHIFT: Day Job

SCHEDULE: Full-time

AIM Specialty Health is a benefit-management leader in Illinois and a proud member of Anthem's family of companies. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.

A proud member of the Anthem Inc family of companies, myNEXUS is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

Job Summary:

Responsible for performing pre-certification, certification and/or authorization activities for Home Health Services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services, responds to a member’s total health needs and ensures the highest quality of continuity of care.

Primary duties may include, but are not limited to:

  • Develops coordinated, collaborative care plans with all involved providers.
  • Reviews Home based services for clinical appropriateness of the continued care.
  • Performs reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff.
  • Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care.
  • Promotes healing and decrease home care utilization.
  • Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.
  • Requests additional clinical information from member’s care providers as necessary.
  • Facilitates timely discharges and transfers based on individual needs and care requirements.
  • Educates patients to help them understand their health choices and assists them in making informed decisions about their health care.
  • Serves as an information resource to patients, health care professionals, facilities, health plan representatives, care givers and family members.
  • Monitors cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed.
  • Refers requests that do not meet coverage guidelines criteria to Physician for review.
  • Uses clinical judgment in authorizations that fall outside of guideline parameters.



Minimum Requirements:

  • Requires RN license and minimum of 5 years of experience in a variety of health care settings; or any combination of education and experience, which provides an equivalent background.
  • urrent, 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 required. C
  • Certifications relevant to wound care, such as WOCN or CWS required. WOCNCB certification preferred.
  • Home health experience preferred.

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.

The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.

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 is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.

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.