Nurse Medical Mgmt Lead, PreD-40478 - (US-OH-Mason - 45040)

Minimum Education: Tech School
Job Type: Full Time
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Anthem Blue Cross and Blue Shield
is a proud member of the WellPoint family of companies. At Anthem, we are dedicated to our mission of improving the health of the people we serve. We believe the best health care coverage can actually help people stay healthy.
Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

The Nurse Medical Management Lead in this position serves as team lead and resource for our Central Region Predetermination staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of 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. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Other responsibilities may include: Conducts predetermination, 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. Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. 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.

Skills:
Qualified candidates will have a current, unrestricted Ohio or Wisconsin RN license and 3-7 years of pertinent clinical or managed care experience and at least 1 to 2 years of predetermination experience. Prior experience with utilization management or the medical review process preferred. Must have knowledge of the medical management process and the ability to interpret and apply member contracts, member benefits, and managed care products. Prior managed care experience required. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Must exhibit leadership skills. Experience with performance auditing helpful. Excellent computer skills required. WellPoint is ranked No. 1 among health insurers on Fortune Magazine's annual list of America's Most Admired Companies and has been named as one of the Top 50 Companies for Diversity by DiversityInc Magazine.

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