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Nurse Medical Mgmt I

Anthem Inc.

This is a Full-time position in Nashville, TN posted February 18, 2021.

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent.

Our Vision.

At Anthem, Inc., it’s a powerful combination, and 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 at one of America’s leading health care companies and a Fortune Top 50 Company.Nurse Medical Management I (Clinical Rationale Team)Work schedule: M-F 8:30 am to 5:00 pm EST with a rotation of evening shiftsLocation: Remote
– within 1-hour commuting distance to any Anthem locationPreferred locations: CA, WA, NV, IN, TN, VA CRT (Clinical Rationale Team) nurses are responsible for overseeing denial decisions made for the Medicare Advantage enrolled members in accordance and are compliant with applicable criteria, medical policy, member eligibility, benefits, and contracts by working with Anthem Medical Directors and other medical management staff.

Responsibilities include but not limited to:
• Daily production of generation of Medicare driven denial letters
• Appropriate guideline used to render denial decision
• Assuring HIPAA verification
• Research and interpretation of member contracts coverage
• Working knowledge of CPT, ICD10 codes, Facility-based revenue codes
• Verifying codes in PLUTO
• Resource and assistance to our MMS (Medical Management Specialist) as needed
• Resource for UM partners for guidance for appropriate denial processingQualifications
• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state you reside
• Requires 3 years of clinical experience
• Requires experience with electronic documentation/medical management systems
• Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Requires solid skills in Microsoft Office (Excel and Outlook)
• Preferred experience working with Medicare and Medicaid
• Preferred experience working with ACMP, SharePoint
• Preferred experience with CMS (Medicare) and MCG guidelines
• Preferred knowledge of Medicare guidelines
• Preferred Utilization management experience
• Preferred managed care experienceWe offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

An Equal Opportunity Employer/Disability/Veteran.Anthem, Inc.

is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes.

To learn more about our company and apply, please visit us at

An Equal Opportunity Employer/Disability/Veteran.

Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

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