Anthem Licensed Utilization Review II (LPN/LVN) -Plantation, FL 129577 in New York, New York

/ Your Talent. Our Vision. / At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care .

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

Licensed Utilization Review II Nurse-Plantation, FL

The Licensed Utilization Review Nurse is responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include:

  • Review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.

  • Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.

  • Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.

  • Applies clinical knowledge to work with facilities and providers for care-coordination.

  • May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.

  • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.

  • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

  • Requires a current unrestricted LPN or LVN license in Florida; 2 years of clinical or utilization review experience; 1 year of managed care experience and knowledge of the medical management process; or any combination of education and experience, which would provide an equivalent background.

  • Previous Medicaid managed care experience preferred.

  • Utilization management experience preferred.

  • Long term care experience preferred.

/ Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at // antheminc.com/careers // . EOE. M/F/Disability/Veteran. /

Job Medical

Title: Licensed Utilization Review II (LPN/LVN) -Plantation, FL 129577

Location: NY-New York

Requisition ID: 129577