WellPoint is one of the nation's leading health benefits companies and a Fortune Top 50 company. At WellPoint, we are working together to transform health care with trusted and caring solutions. Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people’s lives, and to take your career further than you can imagine.
This position is located in Central, CA (Fresno and surrounding counties).
Responsible for managing a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to: Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting. Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources. Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requires a BS in nursing; 5 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted California RN license required. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Knowledge of Milliman guidelines required. Understanding of UM processs required. Previous Utilization Management experience or hospital based case management, discharge planning required. Managed care and Medicaid experience is preferred. Leadership/management experience required.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers. EOE. M/F/D/V.
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