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Anthem, Inc. RN Telephonic Inpatient Utilization Review l, ll, Sr - California (PS33871) in Mendota Heights, Minnesota

RN Telephonic Inpatient Utilization Review l, ll, Sr - California (PS33871)

Location: United States


Requisition #: PS33871

Post Date: 1 day ago

Your Talent. Our Vision. At Anthem Blue Cross , a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and 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.

Work Location : California residents only. Work from our Newbury Park or Woodland Hills office until training is complete, up to 6 months, then may have the option to work remotely in California.

The Nurse Medical Management l, ll, and Sr. roles are responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to:

  • Conducts pre-certification, continued stay review, care coordination, or discharge planning for 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.

  • 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.


  • Current active, unrestricted RN license topractice as a health professional within the state of residence; 2 plus yearsacute care clinical experience is strongly desired. (3 – 5 years for the levelll and prior managed care experience required for the Sr. Level.)

  • Previous Utilization Management experience isstrongly desired.

  • Managed care experience is preferred.

  • Requires strong oral, written and interpersonalcommunication skills, problem-solving skills, facilitation skills, andanalytical skills.

  • EOE.M/F/Disability/Veteran

*May be hired as a Nurse Medical Manager l,ll, or Sr depending upon level of education, skills, and relevant experience.

Anthem, Inc. is ranked as one of America’sMost Admired Companies among health insurers by Fortune magazine and is a 2018DiversityInc magazine Top 50 Company for Diversity. To learn more about ourcompany and apply, please visit us at AnEqual Opportunity Employer/Disability/Veteran.