Job Description
These candidates will be working in the continued stay review department. They will be looking at emerging urgent inpatient admissions for medical necessity. Strong computer skills, positive attitude, and ability to hit high production goals is what the manager is looking for here. Expected to review 20 cases a day with a 95% accuracy rate.
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources
MAJOR JOB DUTIES AND RESPONSIBILITIES
- 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 precertification, 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 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.
Qualifications
- Must have clear and active RN license in the state of IN
- 2 years of experience in a acute care clinical environment (The candidate should have a strong ER/Critical Care/Med-Surgical clinical background. )
- Knowledge of Millman or Interqual criteria
- Must have prior UM experience
- Needs to be flexible to change
- Experience with reviewing medical records
- Proficient with computers and using MS applications
- Strong written and verbal communication skills
Additional Information
Advantages of this Opportunity:
Competitive salary, negotiable based on relevant experience
Benefits offered, Medical, Dental, and Vision
Fun and positive work environment
$30 - $34 per hour
Monday - Thursday 8am-5pm EST Friday - 9am - 6pm EST Occasional Saturday rotation (8am-Noon) EST
Company Description
Anthem, Inc. is working to transform health care with trusted and caring solutions. Our health plan companies deliver quality products and services that give their members access to the care they need. With more than 73 million people served by its affiliated companies including nearly 40 million enrolled in its family of health plans, Anthem is one of the nation's leading health benefits companies.
One in nine Americans receives coverage for their medical care through Anthem's affiliated plans.
We offer a broad range of medical and specialty products.