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. These positions will be eligible for a $5,000 sign-on bonus. The positions are located in Visalia, CA onsite at the Kaweah Delta Medical Center.
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, 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.
Requires current unrestricted California RN license and 3 - 5 years acute care clinical experience preferably adult care (i.e. Medical Surgical or ICU experience). Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. Prior managed care with a Utilization management focus, or hospital based /case management experience strongly preferred. Medicaid experience preferred. Knowledge of Interqual or Milliman criteria preferred. Previous experience or interest in working in a virtual environment preferred. Willingness to work on-site at select facilities coordinating and managing clinet's discharge plans,and concurrent stay review. CA resident for on-site in Fresno and Sacramento counties. 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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