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Nurse Medical Management
HMC Nurses Change Lives! Come grow with us and help us build some healthier lives, including yours. Join the HMC family where employee well being and satisfaction is the core of our vision. Experience the refreshing difference of a HMC career. HMC (Health Management Corporation) is a wholly owned subsidiary of WellPoint, Inc. The WellPoint family of companies provides health care benefits to approximately 34 million people and is the largest publicly traded commercial Health benefits company in the United States.
Job Description:

Responsible to collaborate 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, 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.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied. Primary duties may include, but are not limited to:

Conducts pre-certification, concurrent, retrospective, out of network and 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.
Job Requirements:
As business needs may require, this position may require additional state licenses either now or in the future. Inability or unwillingness to obtain these required licenses may result in either re-assignment (if available) or termination. Obtaining required licenses is a requirement for continued employment.

Requires current unrestricted RN license in applicable state(s) and 2 years acute care clinical experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Will work until 8pm one evening each week.
Bi-lingual English/Spanish a plus.
Masters degree a plus!