Anthem, Inc. Wound Care UM RN - myNexus, Home Health Remote in Virginia Beach, Virginia
SHIFT: Day Job
Wound Care UM RN Remote
Be part of an extraordinary team We are looking for leaders at all levels of the organization 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 for performing pre-certification, certification and/or authorization activities for health services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services, responds to a member’s total health needs and ensures the highest quality of continuity of care.
Primary duties may include, but are not limited to:
Develops coordinated, collaborative care plans with all involved providers.
Reviews Home based services for clinical appropriateness of the continued care.
Performs reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff.
Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care.
Promotes healing and decrease home care utilization.
Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.
Requests additional clinical information from member’s care providers as necessary.
Facilitates timely discharges and transfers based on individual needs and care requirements.
Educates patients to help them understand their health choices and assists them in making informed decisions about their health care.
Serves as an information resource to patients, health care professionals, facilities, health plan representatives, care givers and family members.
Monitors cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed.
Refers requests that do not meet coverage guidelines criteria to Physician for review.
Uses clinical judgment in authorizations that fall outside of guideline parameters.
Requires RN license.
Minimum of 5 years of experience in a variety of health care settings; or any combination of education and experience, which provides an equivalent background.
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 required.
Certifications relevant to wound care, such as WOCN or CWS required.
WOCNCB certification preferred.
Home Health experience preferred.
We 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. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.