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Anthem, Inc Nurse Medical Management I - Medicaid HCMS - PS29006 in Costa Mesa, California

Nurse Medical Management I - Medicaid HCMS - PS29006

Location: United States

Requisition #: PS29006

Post Date: Oct 21, 2019

Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.

Nurse Medical Management I - Medicaid HCMS

Location - Tennessee

The Nurse, Medical Management is responsible for collaborating with external and internal healthcare providers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources in the in-patient setting.

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, elective surgicalprocedures, and out of network services by evaluating the appropriateness of the treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to the appropriate providers and level of care, as well asprograms or community resources needed at discharge.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.

  • Conducts the review of initial & concurrent authorization requests; retro reviews; elective procedures/in-patient stay reviews; coordination of care and discharge planning in collaboration with the acute care facility Case Management staff, as well as the internal Home Health & Sub-Acute Teams.

  • Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.

  • Routes and/or pends cases requiring second level review to the Health Plan Medical Director to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

  • Communicates determinations to acute care facility and c ollaborates with providers to assess members’ needs for early identification of and proactive planning for discharge.

  • 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.

  • Supports local and corporate cost of care initiatives.


  • Requires 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted RN license in Tennessee is required. AS/BS in nursing preferred.

  • Prior Utilization Management, Case Management or managed care experience preferred

An Equal Opportunity Employer/Disability/Veteran