Anthem, Inc. Nurse Utilization Management - Acute / InPatient - Medicaid in Iselin, New Jersey
SHIFT: Day Job
Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, 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.
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Nurse Utilization Management l – InPatient Medicaid (PS54643)
Location: Work@Home. Must reside in New Jersey or be willing to come to our Iselin, New Jersey office up to 3 times quarterly for meetings.
Work Hours : Standard Business Hours
The Nurse Medical Management l for New Jersey Medicaid 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 for more complex medical issues.
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, 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.
Consults 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 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.
Requires current active unrestricted RN license to practice as a health professional in the state of residence and 3 - 5 years acute care clinical experience.
Requires current, active, unrestricted RN license in New Jersey.
Must have knowledge of medical management / utilization review process within a managed care organization or within hospital / provider organization.
Interqual, Milliman Care Guidelines (MCG), or any medical criteria sets.
Must reside within commuting distance to our Iselin, New Jersey office.
Basic computer skills to include MS Word, Excel, email/calendars.
Clinical InPatient / hospital experience preferred.
Prior managed care experience.
Ability to interpret and apply member contracts, member benefits, and managed care products.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Knowledge of Medicaid.
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 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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