Nurse Care Mgr Sr

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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.Department hours of operations are 8 AM - 9 PM EST. Remote is available. Responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to:Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.

Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

Coordinates internal and external resources to meet identified needs.

Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.

Assists in problem solving with providers, claims or service issues.

Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.

May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.

Participates in audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager.

Serves as first line contact for conflict resolution.

Develops training materials, completes quality audits, and performs process evaluations, and tests and monitors systems/process enhancements.

QualificationsNurse Care Mgr I

Requires 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Home health/discharge planning experience preferred. AS/BS in nursing preferred. Certification as a Case Manager is preferred.Nurse Care Mgr IIRequires 3 years of acute care clinical experience, condition specific clinical experience, home health/discharge planning experience; at least 1 year in a Nurse Care Mgr I role or equivalent experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. AS/BS in nursing preferred. Certification as a Case Manager is preferred. Participation in the American Association of Managed Care Nurses preferred. Prior managed care experience preferred. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.Nurse Care Mgr SrRequires 5 years of acute care clinical experience, condition specific clinical experience, home health/discharge planning experience; case management experience, disease management experience, broad clinical knowledge base of disease processes; at least 1 year in Nurse Care Mgr II role or equivalent experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. AS/BS in nursing preferred. Certification as a Case Manager is preferred. Certification in the American Association of Managed Care Nurses preferred. Prior managed care and case management experience preferred. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred; or any combination of education and experience which would provide an equivalent background. Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field also preferred.Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.REQNUMBER: PS40792