Anthem Nurse Medical Mgmt I/II/Sr (PSCCR) - Any Commercial Anthem State (Telecommute) - RN License Required - 135466 in Baltimore, Maryland

/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.

**Location: Candidates can be located anywhere in the US, however, they need to be licensed in one of the following states:

  • California
  • Colorado
  • Indiana
  • Kentucky
  • Missouri
  • Nevada
  • Ohio
  • Wisconsin
  • Connecticut
  • Georgia
  • Maine
  • New Hampshire
  • New York
  • Virginia

Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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, focused surgical and diagnostic procedures, 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.
  • Applies clinical knowledge to work with facilities and providers for care coordination.
  • Works with medical directors in interpreting appropriateness of care and accurate claims payment.
  • May also manage appeals for services denied.
  • Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
  • Consult 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 members 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.

*Please note that this position can be filled as Nurse Medical Management I, II, or Sr. The hiring manager will determine the level, based on the candidate's experience and background.


**Nurse Medical Management I/II/Sr

  • Requires current active unrestricted RN license to practice as a health professional in Colorado or Nevada and at least 3 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background.
  • Participation in the American Association of Managed Care Nurses preferred.
  • Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
  • Prior managed care experience strongly preferred.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

    This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.

    **/ Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2016 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. /

Job Medical

Equal Employment Opportunity Statement Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.

Title: Nurse Medical Mgmt I/II/Sr (PSCCR) - Any Commercial Anthem State (Telecommute) - RN License Required - 135466

Location: maryland-Baltimore

Requisition ID: 135466