Anthem, Inc. Mgr II Medical Mgmt (Grievance & Appeals) in Walnut Creek, California
SHIFT: Day Job
Your 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
Mgr II, Medical Mgmt
Location: Candidates must reside in California. This position is temporarily designated as work at home. Once the office reopens, if required, must be willing to work on-site at one of our California offices.
Responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing 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.
Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
Develops and manages annual operating budget. Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requires 5 years of acute care clinical experience; 2 years or prior management experience; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
Candidate must reside in California
Experience with DHMC, appeals and grievances for California market highly desired.
For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.