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Anthem, Inc. RN Nurse Medical Mgmt I/II - Medicare in Albany, New York


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 healthcare.

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.

LOCATION: This is a remote from home position. Residency in NY, NJ, CT, CO, or NV is highly preferred.

HOURS: Monday through Friday, general business hours. Occasional evening or weekend hours may be required.

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and 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, focused surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting. Utilizes the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources.

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.

  • Works with medical directors in interpreting appropriateness of care and accurate claims payment.

  • May also manage appeals for services denied.


Required qualifications:

  • A current active unrestricted RN license to practice as a health professional from the state in which you reside, and you must hold a compact license or be willing to become licensed in other states as required.

  • Knowledge of the medical management process and the ability to interpret and apply member contracts and member benefits.

  • For Nurse Med Mgmt I: 2 years of acute care clinical experience.

  • For Nurse Med Mgmt II: 3-5 years of acute care clinical experience and utilization management/review experience.

    Preferred qualifications:

  • For Nurse Med Mgmt I: prior utilization management/review experience.

  • Previous experience in a managed care setting.

  • Experience working with Medicare and/or Medicaid members.

  • Previous discharge planning experience.

  • You should be knowledgeable in Microsoft Word, Excel, and Outlook.

Applicable to Colorado Applicants Only Annual Salary Range*: $58,720 - $73,400 Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. * The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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 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.