WellPoint is one of the nation's leading health benefits companies and a Fortune Top 50 company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to simplify the connection between health, care, and value for our customers. Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine. This position is located in Fresno on-site at the Community Medical Center Fresno. 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 more complex 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 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. May participate in or lead intradepartmental teams, projects and initiatives.
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 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 2012 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers. EOE
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