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.
Responsible for collaborating 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. Primary duties may include, but are not limited to: 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. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, 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. 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 member's 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. Serves as resource to lower-leveled nurses. May participate in or cross-functional teams, projects and initiatives, process improvement activities. May serve as departmental liaison to other areas of the business unit.
Requires AS/BS in nursing; 3 - 5 years acute care clinical experience, preferably adult care (i.e. Medical surgical or ICU); or any combination of education and experience, which would provide an equivalent background. Current unrestricted California RN license required. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. Prior Medicaid managed care experience with a Utilization Management focus preferred, or hospital based case management/ discharge planning. Knowledge of the Continued stay review process preferred. Excellent computer skills with knowledge of Microsoft applications 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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