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Anthem, Inc. Nurse Case Mgr I/II/Sr FHPS in Reston, Virginia

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 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 at one of America's leading health benefits companies and a Fortune Top 50 Company.

Location: Atlanta, GA, Indianapolis, IN or Richmond, VA offices.

Shift: 10-6:30 pm EST.

Nurse Case Manager I

Responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to:

  • Ensures member access to services appropriate to their health needs.

  • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

  • Coordinates internal and external resources to meet identified needs.

  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

  • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.

  • Negotiates rates of reimbursement, as applicable.

  • Assists in problem solving with providers, claims or service issues.

Nurse Case Manager II

Responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically.

Primary duties may include, but are not limited to:

  • Ensures member access to services appropriate to their health needs.

  • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.

  • Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

  • Coordinates internal and external resources to meet identified needs.

  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

  • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.

  • Negotiates rates of reimbursement, as applicable.

  • Assists in problem solving with providers, claims or service issues.

  • Assists with development of utilization/care management policies and procedures.

Nurse Case Mgr Sr

Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. 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:

  • 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.

  • Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.

  • Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.

  • Implements and coordinates a care plan; monitors and evaluates effectiveness of the care management plan and modifies as necessary.

  • Serves as resource to lower-level nurses; functions as preceptor for new care management staff.

  • Assists with development of care management policies, procedures, and new programs.

  • Participates in or leads intradepartmental and cross-functional teams, projects and initiatives, process improvement activities.

  • Serve as departmental liaison to other areas of the business unit and/or cross brand workgroups.

Qualifications

Nurse Case Manager I

  • Requires a BA/BS in a health related field; 3 years of clinical 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.

  • Certification as a Case Manager is preferred. For URAC accredited areas the following applies:

  • Current and active RN license required in applicable state(s).

  • 5 years of experience, certification as a Case Manager from the approved list of certifications, and a BS in a health or human services related field preferred.

  • Nurse Case Manager II

  • Requires a BA/BS; 5 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background.

  • Current and active RN license required in applicable state(s).

  • 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 and a BS in a health or human services related field preferred.

Nurse Case Mgr Sr

  • Requires 5 years of acute care clinical experience, condition specific clinical experience, home health/discharge planning experience; case management experience, disease management experience, broad clinical knowledge base of disease processes; at least 1 year in Nurse Care Mgr II 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 managed care and 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.

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. An Equal Opportunity Employer/Disability/Veteran.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.

REQNUMBER: PS45167-Virginia

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