Anthem, Inc. Wound Care UM RN (myNEXUS) WOCN/CWS - REMOTE in Coconut Grove, Florida
SHIFT: Day Job
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, 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.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. 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.
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.
Current, 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.
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. 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.