Nurse Medical Management (RN) Remote-Home Health

Anthem, Inc. in Arrington, TN

position filled
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.
Location: Must reside in Tennessee - Montgomery, or surrounding counties, for close proximity to territory.
Note: This position requires day travel throughout Tennessee up to 2 hours one way. Mileage will be reimbursed.
The Nurse Medical Management l (Home Health) is responsible for collaborating 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. Primary duties may include, but are not limited to:
Visit members in their homes up to 4 - 5 days per week to conduct pre-certification, continued stay review, care coordination, or discharge planning assessments for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

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.

Current active unrestricted RN license to practice as a health professional in the State of Tennessee.

Minimum 1 - 2 years home health care or private duty nursing clinical experience.

Internet Access - Home office.

Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Ability to assess member needs for home care services by gathering documentation and home visits.

Must reside in the Middle Tennessee and be willing and able to work in the field up to 4 - 5 days per week, travelling as much as 2 hours one way.

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