Nurse Medical Mgt (Job Family)-19608

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

Develops favorable working partnership(s) and relationships with members, physicians, healthcare service providers, internal and external customers to improve health outcomes for members. Participates in activities that result in member access to medically necessary, quality healthcare in the most appropriate and cost effective setting. Facilitates communication among members, the healthcare delivery system and WellPoint. Ensures member access to medically necessary quality care while satisfying requirements of member contracts. Facilitates member care transition through the health care continuum. Conducts pre-certification, concurrent and retrospective reviews (may handle complex cases). Guides the member into utilization of contracted physicians, facilities and healthcare service providers. Early identification and proactive planning for discharge needs. Refers treatment plans/Plan of Care to Peer Clinical Reviewers (PCR) as required. Works in partnership with hospitals and healthcare service providers.

Associate's Degree in Nursing or the equivalent. Current unrestricted RN license in applicable states. Two years acute clinical experience. One year prior equivalent medical management experience preferred. Preferred: A minimum of three years acute clinical experience OR any combination of education/experience, which would provide an equivalent background. Knowledge of utilization management processes. Knowledge of appropriate physicians and health care service providers. Strong understanding of appropriate member contracts and awareness of contract benefits. Strong people skills sufficient to establish positive, collaborative relationships with members, families, providers, etc. Demonstrated customer service orientation. Negotiation and facilitation skills. Ability to train and coach lower level Medical Management Nurses and team members. Ability to work on multiple projects. Strong organizational, problem solving and decisionmaking skills. Ability to make sound decisions based on clinical judgment, established clinical guidelines and individual circumstances. Knowledge of PCs and related applications such as Excel, Word, Access, etc. Effective oral and written communication skills.