Anthem Nurse Utilization Management I - Remote - SC Medicaid - PS6472 in Wichita Falls, Texas

Nurse Utilization Management I - Remote - SC Medicaid - PS6472


Location: Columbia, South Carolina, United States

Field: Medical

Requisition #: PS6472

Post Date: 5 days ago

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 benefits companies and a Fortune Top 50 Company.

Nurse Utilization Management I – SC Medicaid

Location: Remote – Prefer residents of South Carolina but will consider applicants outside of South Carolina

The Nurse Medical Management I collaborates 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, focused surgical procedures, out of network services, and appropriateness of treatment setting and level of care by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products. Works with medical directors in interpreting appropriateness of care.

Primary duties may include, but are not limited to:

  • Conducts 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.


  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of South Carolina, or within the state reside if outside of South.

  • 2 years acute care clinical experience, plus at least 2 years’ of experience of CSR (inpatient).

  • 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 is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at EOE. M/F/Disability/Veteran.