Anthem Blue Cross and Blue Shield is a proud member of the WellPoint family of companies. At Anthem, we are dedicated to improving the lives of the people we serve and the health of our communities.
Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.
Work schedule: 8:30am to 5:00pm M-F
Location: Richmond, VA
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. 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. May participate in or lead intradepartmental teams, projects and initiatives.
Requires current unrestricted Virginia RN license; 3 years acute care clinical experience; or any combination of education and 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 and Medicaid experience strongly preferred. Previous Medical Management, Inpatient/outpatient reviews and UM experience preferred. Trimed system experience preferred. Knowledge of Milliman guidelines preferred.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2012 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers . EOE
Once an offer is accepted, all external applicants are subject to a background investigation
and if appropriate, drug testing. Offers of employment shall be contingent upon
passing both the background investigation and drug testing (if required).
associate referral process on WorkNet. Official guidelines for the associate referral
- Current WellPoint associates: All referrals must be submitted through the formal
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We recently changed our name from WellPoint to Anthem, Inc., the name people know us by best. As our companies continue to take a more...