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Anthem, Inc. Nurse Care Mgr Ld in Placentia, California

Description

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 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 benefits companies and a Fortune Top 50 Company.

RN Care Manager Lead-NICU Locations: CA; Position is W@H, but must be within a commutable distance to an Anthem office. Hours: 8:00 am - 5:00 pm EST

RESPONSIBILITIES: Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Serves as a team lead for nursing staff that collaborate with healthcare providers and members. Performs care management activities within the scope of licensure for members with complex and chronic care needs. Primary duties may include, but are not limited to: Maintains an active case load of the most complex cases and assists team members in the delivery of disease management programs; provides guidance and assistance with clinical, program, and client specific questions and situations. 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 and level of care. Serves as resource to lower-level nurses; functions as preceptor for new care management staff. Serves as first line contact for conflict resolution. Develops training materials, completes quality audits, and performs process evaluations, and tests and monitors systems/process enhancements. Assists with development of care management policies, procedures, and new programs. Monitors assigned telephone skill groups and work volumes to meet performance expectations as related to call volume, call length, and productivity. Identifies potential obstacles and reports possible solutions. Requires 7 years of acute care clinical experience, 2 years of disease management experience, broad clinical knowledge base of disease processes, home health/discharge planning experience, managed care experience and leadership experience; at least 2 years in Nurse Care Mgr II role or 1 year in Nurse Care Mgr Sr role or equivalent experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. AS/BS in nursing preferred. Certification as a Case Manager is preferred. Certification in the American Association of Managed Care Nurses preferred. Prior case management experience preferred. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred; or any combination of education and experience, which would provide an equivalent background. Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field also preferred. Team leads must hold a certification as a case manager within 3 years of starting the CM Team Lead role. 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.

Qualifications

QUALIFICATIONS: Requires 7 years of acute care clinical experience, 2 years of disease management experience, broad clinical knowledge base of disease processes, home health/discharge planning experience, managed care experience and leadership experience; at least 2 years in Nurse Care Mgr II role or 1 year in Nurse Care Mgr Sr role or equivalent experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. AS/BS in nursing preferred. Certification as a Case Manager is preferred. Certification in the American Association of Managed Care Nurses preferred. Prior case management experience preferred. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred; or any combination of education and experience, which would provide an equivalent background. Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field also preferred. Team leads must hold a certification as a case manager within 3 years of starting the CM Team Lead role. Must have NICU clinical experience Milliman experience preferred Licensure in CO, NV and CA preferred, but not required.

REQNUMBER: PS51896

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