Job ID: JP00043595

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for contract workers (via BCforward) who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

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.

Must have a current active RN license in the state of MN.

Primary duties may include, but are not limited to:

• Conducts pre-certification, continued stay review, care coordination, or discharge planning for 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.

Requirements:

• Current active, unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.
• 2 years acute care clinical experience.
• Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Must have MN RN Licensure.
• Computer literate, Medicaid knowledge a plus, IP medical necessity review experience a plus.
• Prefer ICU, ER, and Medical/surgical experience nurses.
• Prefer RN to have at least a combined 5 years of experience in above mentioned areas.

Additional Details:

• M - F (with one Saturday on Dec. 23rd), 8am - 5pm CST.
• Remote, work from home opportunity.

BCForward is An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

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